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Remote Cognitive Testing and Perioperative Risk: Enhancing Access for Older Adults in Rural Areas

Victoria Liu, BS and Bernadette Wilks, MBBS

Implementing perioperative best practices remains challenging when many patients, often due to logistical, social or medical barriers, are unable to attend their preoperative appointments. These gaps are especially pronounced among older adults who already face significant social and structural obstacles to accessing hospital-based care. At the same time, an aging population and continued advances in surgical techniques means older adults now make up a growing share of the surgical population, accounting for 38% of all surgeries in 2024.1

Postoperative delirium is common, preventable in 40% of cases,2 and linked with increased costs, mortality and morbidity.3 Older adults also face more than an elevenfold increased risk of postoperative delirium.4 Expanding access to preoperative evaluation and aligning best practices with the realities of modern perioperative care pathways are essential steps toward meaningfully improving outcomes.

One promising approach to reach patients who struggle to attend in-person preoperative visits is to offer brief, remote assessments delivered through their personal devices. These tools are inexpensive, widely accessible, and give clinicians a meaningful pre-surgical snapshot of a patient’s baseline brain health, something that typically requires in-clinic cognitive testing and dedicated staff.

A recent prospective pilot study published in Anesthesia and Analgesia by Dr. Barreto Chang and colleagues at the University of California San Francisco highlights the feasibility of this approach.5 Patients completed a gamified, smartphone-based cognitive tests prior to surgery, and the researchers evaluated both usability and postoperative delirium outcomes. The remote assessment showed strong promise in detecting baseline cognitive impairment and predicted postoperative delirium at least as well as the Montreal Cognitive Assessment (MoCA), especially when combined with a question about subjective cognitive decline.

Taken together, these early findings suggest that easy-to-use and widely accessible perioperative digital tools may strengthen cognitive risk stratification and, ultimately, improve surgical outcomes by reducing perioperative cognitive decline. Perhaps of even greater importance is the potential to overcome long-standing barriers to perioperative healthcare such as cost, transportation, and caregiver responsibilities by bringing assessments directly to patients on their own devices. This is particularly impactful for patients in rural communities, where even a single clinic visit can require hours of travel, missed work, or dependence on limited public transit, and where accessible digital pathways could meaningfully expand equitable surgical care.

  1. McSwain J. Age. American Society of Anesthesiologists, Made For This Moment. Accessed November 15, 2025. https://madeforthismoment.asahq.org/preparing-for-surgery/risks/age/
  2. Hshieh TT, Yue J, Oh E, et al. Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med. Apr 2015;175(4):512-20. doi:10.1001/jamainternmed.2014.7779
  3. Vasilevskis EE, Han JH, Hughes CG, Ely EW. Epidemiology and risk factors for delirium across hospital settings. Best Pract Res Clin Anaesthesiol. Sep 2012;26(3):277-87. doi:10.1016/j.bpa.2012.07.003
  4. Fenta E, Teshome D, Kibret S, et al. Incidence and risk factors of postoperative delirium in elderly surgical patients 2023. Nature. 2025;15(1):1400. doi:10.1038/s41598-024-84554-2
  5. Barreto Chang, Odmara L., Wise, Amy B., Sinha, Anika, Possin, Katherine L., Boxer, Adam, Staffaroni; and Collaborators. Remote Cognitive Testing for Detection of Baseline Cognitive Impairment and Prediction of Postoperative Delirium Risk: A Pilot Study. Anesthesia & Analgesia ():10.1213/ANE.0000000000007843, December 08, 2025. | DOI: 10.1213/ANE.0000000000007843
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