Abstract and Introduction
Abstract
In this Pro-Con commentary article, we discuss the risks and benefits of administering preoperative benzodiazepines to older patients to decrease preoperative anxiety. The Pro side first focuses on the critical importance of treating preoperative anxiety and that benzodiazepines are the best tool to achieve that goal. The competing argument presented by the Con side is that myriad options exist to treat preoperative anxiety without simultaneously increasing the risk for devastating complications such as postoperative delirium. Both sides call for more high-quality investigations to determine the most effective strategies for decreasing preoperative anxiety in older adults while improving outcomes and reducing morbidity.
Introduction
High preoperative anxiety levels are present in 40% to 65% of patients.[1,2] Left untreated, preoperative anxiety is associated with increased postoperative pain, opioid requirements, postoperative anxiety, delirium, 4-year mortality, and decreased patient satisfaction scores.[3–9] Preoperative anxiety is emotionally distressing, and patients desire anxiolytic medications and the support of their anesthesiologist in coping with the anxiety.[1,10] This may be why preoperative benzodiazepine administration to older patients remains commonplace despite many multidisciplinary clinical guidelines recommending avoidance.[11–13] In fact, recent studies have shown that 38% to 65% of older patients received benzodiazepines during anesthesia care.[14,15] The recommendation to avoid preoperative benzodiazepines often stems from efforts to avoid postoperative delirium. Postoperative delirium is the most common complication in older patients and is associated with severe consequences, including prolonged hospital stay, functional decline, institutionalization, mortality, worse cognitive trajectory after surgery, and the development of dementia.[16–19] Recent literature has called into question whether preoperative benzodiazepine administration for anxiolysis is associated with increased delirium.[20] Unfortunately, we lack high-quality evidence of whether a single dose of a preoperative benzodiazepine increases the risk of postoperative delirium and other complications or if it is associated with added benefit through superior anxiolysis. In this Pro-Con commentary article, we discuss 2 opposing arguments for and against judicious benzodiazepine administration for preoperative anxiolysis in older patients based on the current state of the literature.
Anesth Analg. 2023;137(2):280-288. © 2023 International Anesthesia Research Society
