July 1, 2026 Salus Health Care Forum

But interestingly, the highest incidence of postoperative delirium comes with hip fractures, which are fairly common up to age 70. 72% of hip fractures experience some form of postoperative delirium. The type of anesthetic is important, My bias has always been to do a regional, thinking that would have less effect on postoperative cognition. However, my assumption has not really panned out. Regional extremity, use of fewer narcotics, has more often panned out. But hip surgery, which is a fairly common, any femoral neck fixation procedure, is associated with a very high risk of postoperative delirium.

Perry

Mark and Gay, I want to thank you for bringing the subject up because it’s actually something that crossed my mind. In ancient times, as a med student, I worked as a research tech for the anesthesia department. So I spent a lot of time in anesthesia cases over those years. And I remember they made the point to the residents that they needed to keep in mind that what anesthesia actually does. You’re poisoning somebody into unconsciousness so that you can operate on them. And then you must save them and bring them back to life. And so that really impressed me as to the impact of what’s being done. But Mark, your comment raised a question for me. I wondered if you saw a difference in the cognitive issues with the types of anesthetics.

I’m specifically thinking about inhalation anesthetics that are fat soluble. You saturate your bodies and your brain tissue with this material that may take a great deal of time to actually clear out. You mentioned opioids, but I wondered if the fat soluble anesthetics have a similar impact.

Mark

Well, it’s interesting that you should say that because the inhalation anesthetics, as they developed, halothane was used widely as an induction agent for kids because it was sweet and it was easily acceptable to kids. You could literally drop it over them and get them asleep and then start an IV. The newer anesthetics are less fat soluble. My bias has always been toward a combination of regional and a lighter or general anesthetic or inhalation agent or mixed with propofol, which clears very rapidly. But like I said, the evidence so far from the prospective trials have not really borne that out. And I think from the reading I did for this talk, there is reason to believe that the cognitive reserve is really key to what’s going in.

It comes down to really basic family practice issues. The least vulnerable are those people walk and are active. There’s no real solid metric, but there’s many proxies. The number one is level of education. Other ones are reading, playing an instrument, and emailing. Each of those activities decrease postoperative delirium by about 8%. And, you know, I’m kind of disappointed with the results so far that don’t bear that out on the fat soluble because that was always my prejudice.

In my career, I usually, whenever possible, did a combination of a regional plus a general so that I used a less inhalation agent.