The growing population of elderly surgical patients has increased interest in perioperative strategies that improve recovery while minimizing complications. Glucocorticoids, particularly dexamethasone, are frequently administered in anesthesia practice for prophylaxis of postoperative nausea and vomiting (PONV), reduction of inflammatory responses, and opioid-sparing analgesia. In elderly surgical patients, however, the balance between benefits and risks with glucocorticoids is more nuanced because of frailty, multimorbidity, altered pharmacodynamics, and heightened susceptibility to neurocognitive complications. 

Elderly patients experience heightened inflammatory responses to surgery, which contribute to postoperative pain, delirium, pulmonary dysfunction, and prolonged recovery. Glucocorticoids exert potent anti-inflammatory effects through inhibition of cytokine release and modulation of immune signaling. These mechanisms have prompted investigation into whether perioperative glucocorticoids may reduce postoperative delirium and perioperative neurocognitive disorders in elderly patients, who are at higher risk of cognitive impairment following surgery and anesthesia. Recent literature suggests that intravenous glucocorticoids may reduce the incidence of postoperative delirium in major non-cardiac surgery, although evidence remains mixed and somewhat procedure-dependent. 

Dexamethasone remains the most studied corticosteroid in anesthesia literature. A single perioperative dose of 4–10 mg has demonstrated efficacy in reducing PONV and improving postoperative analgesia through opioid-sparing effects. In elderly patients, minimizing opioid exposure is particularly important because opioids are strongly associated with respiratory depression, sedation, ileus, and delirium. Steroid-mediated reduction in postoperative pain may therefore indirectly support cognitive recovery and earlier mobilization. Additionally, some studies have shown reduced fatigue and improved quality of recovery scores following dexamethasone administration. 

The relationship between glucocorticoids and postoperative delirium remains controversial. Neuroinflammation is believed to play a major role in delirium pathogenesis, especially in frail elderly patients. Meta-analytic data suggest glucocorticoids may decrease delirium incidence after major non-cardiac surgery, including orthopedic procedures, but similar benefits have not been consistently observed in cardiac surgery populations. Differences in surgical stress, cardiopulmonary bypass–related inflammation, steroid dosing, and delirium screening methods likely contribute to the heterogeneity of findings. 

Other potentially adverse effects of glucocorticoids require them to be used judiciously in elderly patients. Hyperglycemia is the most consistently observed adverse effect and may be clinically significant in elderly patients with diabetes or impaired glucose tolerance. Steroids may also increase infection risk, impair wound healing, and precipitate steroid-induced psychosis or agitation in vulnerable individuals. Frailty further complicates decision-making because physiologic reserve is diminished and adverse drug effects may be magnified. Current geriatric anesthesia literature emphasizes individualized risk stratification and multimodal delirium prevention strategies rather than reliance on a single pharmacologic intervention. 

For anesthesiologists, glucocorticoid administration in elderly surgical patients should therefore be tailored to surgical magnitude, baseline cognitive status, diabetic control, and frailty profile. In low-risk elderly patients undergoing major non-cardiac surgery, a single perioperative dose of dexamethasone appears reasonable and may provide meaningful benefits in analgesia and recovery quality. However, caution is warranted in patients with poorly controlled diabetes, active infection, severe frailty, or preexisting psychiatric disease. Future randomized trials focused specifically on geriatric surgical populations are needed to clarify optimal dosing, timing, and patient selection. 

References 

1. Li C, Zhang Z, Xu L, et al. Effects of intravenous glucocorticoids on postoperative delirium in adult patients undergoing major surgery: a systematic review and meta-analysis with trial sequential analysis. BMC Anesthesiol. 2023;23:399. 10.1186/s12871-023-02359-8 

2. Li LQ, Wang C, Fang MD, Xu HY, Lu HL, Zhang HZ. Effects of dexamethasone on post-operative cognitive dysfunction and delirium in adults following general anaesthesia: a meta-analysis of randomised controlled trials. BMC Anesthesiol. 2019;19:113. 10.1186/s12871-019-0783-x 

3. Wang Y, Chen J, Liu X, et al. Effects of glucocorticoids on postoperative neurocognitive disorders in adult patients: a systematic review and meta-analysis. Front Aging Neurosci. 2022;14:939848. 10.3389/fnagi.2022.939848 

4. Zhang H, Liu Y, Wang J, et al. Effects of glucocorticoids on postoperative delirium in patients undergoing elective non-cardiac surgery: a systematic review and meta-analysis. Heliyon. 2024;10:e40914. 10.1016/j.heliyon.2024.e40914 

5. Chung J, Patel M, Nguyen T, et al. Managing geriatric syndromes in perioperative care: implications for anesthesia practice. J Clin Anesth. 2025;107:112023. 10.4097/kja.19391