Precision Sedation for Gastrointestinal Endoscopy in Older Adults: Brain Vulnerability and Recovery

Older adults undergoing gastrointestinal endoscopy are particularly susceptible to oversedation, hypotension, hypoventilation, hypoxemia, and delayed recovery because physiological and cognitive reserve decline with age. Precision sedation provides a practical approach to these problems by tailoring drug selection, dose titration, monitoring, and supportive measures to the individual patient and the requirements of the procedure. Propofol remains widely used because of its rapid onset and predictable recovery, although cardiorespiratory depression remains dose dependent. Remimazolam and ciprofol may offer greater hemodynamic or respiratory stability in selected patients, while dexmedetomidine and combination regimens can reduce exposure to other sedatives but introduce their own limitations. Monitoring with processed electroencephalography, cerebral oximetry, capnography, and routine hemodynamic assessment may help identify excessive sedation or physiological deterioration when findings are interpreted in clinical context. However, improvements in short-term cardiopulmonary outcomes or recovery should not be assumed to prevent postoperative delirium or longer-term cognitive impairment. In older adults, sedation should therefore aim for the minimum effective depth while avoiding excessive drug exposure and promptly correcting respiratory and circulatory disturbances. Further endoscopy-specific studies are needed to determine whether these strategies improve cognitive and functional recovery.