Safety-First, Severity-Adapted Enhanced Recovery After Surgery for Patients with Neurodegenerative Disorders: A Narrative Review and Proposed Framework

Enhanced Recovery After Surgery (ERAS) pathways have been shown to improve perioperative outcomes in broad surgical populations. However, their safety, feasibility, and optimal adaptation remain uncertain in patients with neurodegenerative disorders (NDDs), particularly those with dementia and Parkinson’s disease. These patients often present with cognitive impairment and disability, which pose major perioperative care challenges. Our narrative review elucidates the pathophysiological traits, perioperative risks, and medication-related complications of patients with NDDs. We determine potential risks related to standard ERAS components, outline important drug-drug interactions between frequently prescribed NDD medications and anesthetic agents. We also offer useful suggestions for preoperative evaluation, intraoperative management, postoperative recovery, and post-discharge rehabilitation. We then present a three‑tier severity‑adapted ERAS framework, in which patients are stratified into mild, moderate, or severe groups based on the Hoehn and Yahr staging scale for Parkinson’s disease and the Clinical Dementia Rating for dementia. This framework provides recommendations for the retention, modification, or restriction of ERAS components. We postulate that in this vulnerable population, the stratified decision-making pathways may help preserve the benefits of enhanced recovery while reducing avoidable iatrogenic harm and improving clinical feasibility. This, however, represents a conceptual framework requiring prospective validation.