It’s not the anesthesia
Postoperative neurocognitive decline is a misunderstood condition often associated with anesthesia. However, the truth is more complicated.
Postoperative neurocognitive decline is a common condition in older adults that can leave both patients and families with a lot of questions. It can present as delirium, long-term cognitive dysfunction, memory loss, executive function difficulties, and more.
Itay Bentov, MD, PhD, Associate Professor of Multispecialty Anesthesiology at the University of Washington in Seattle, said the older adult population is particularly at risk for postoperative neurocognitive decline for several reasons.
“It is likely due to a convergence of age-related, multifaceted vulnerability, surgery-induced neuroinflammation, and a high prevalence of preexisting (often unrecognized) cognitive impairment,” he said. “About a third of older patients without known neurocognitive deficits have significant cognitive impairment on preoperative testing.”
Helping patients and their families deal with postoperative neurocognitive decline and its aftermath will be the focus of the Monday session, “What Should I Tell My Patients and Their Family About Postoperative Neurocognitive Decline?”
Recognizing which patient groups are most at risk can be an important step in mitigating the risk of postoperative neurocognitive decline before it happens, said Dr. Bentov, who will be a presenter at the session.
“There are patient-related risk factors such as age, frailty, and poor cognitive impairment as well as other factors such as polypharmacy, comorbidities burden, lower educational levels, and sensory impairment,” he said. “And some surgical procedures are at high risk for postoperative neurocognitive decline, including cardiac procedures, hip replacements, major abdominal surgeries, and any prolonged surgery.”
Another step is discussing the potential issues with the patient and their family, said session presenter Elizabeth Whitlock, MD, MSc, Associate Professor of Anesthesiology at the UCSF School of Medicine in San Francisco. She said delirium is one of the easiest issues to discuss because it has been one of the most studied.
“I discuss that one just like any other risk of surgery or anesthesia: ‘Here are the symptoms. If you or your family notice any of them, please tell the nurse to let your team know. They can and will institute common sense, nonmedication risk reduction strategies and look for an explanation that can be treated,’” she said.
Dr. Whitlock said encouraging the patient or family members to speak up about any cognitive change after surgery is important. Likewise, the anesthesiologist or physician must recognize when the symptoms are more than just the anesthesia.
“If a patient notices durable cognitive change after surgery, they should absolutely talk to their primary physician about it. [The physician] can initiate an age-appropriate cognition workup and take into consideration any of their coexisting medical problems,” she said. “Critically, the symptoms of cognitive nonrecovery should not be dismissed as ‘it’s just the anesthesia.’”
Although many patients, their families, and sometimes even physicians, including anesthesiologists, may believe patients are just reacting to the anesthesia when they experience any form of postoperative neurocognitive disorder, Dr. Whitlock said there is little evidence that anesthesia is the culprit.
“But if it’s not anesthetics, then what? We don’t really have a diagnosis. Is it inflammation? Covert stroke? The unmasking of preexisting cognitive vulnerability or neurocognitive disorders like frontotemporal dementia? Most postoperative neurocognitive decline is never diagnosed, nor is a causal explanation identified,” she said.
This, Dr. Whitlock said, is an area where simply knowing as much about your patient as possible could provide the answers.
“In order to do a better job taking care of patients who don’t cognitively recover, we need to know the plausible contributors to their experience,” she said. “It could even be something like depression or anxiety, both of which can certainly worsen postoperatively and are potentially treatable.”
Dr. Whitlock said another area where anesthesiologists may struggle when talking about postoperative neurocognitive decline is in translating the existing literature on neurocognitive test performance into something easily digestible.
“The tests we’ve used are hard to analogize to the symptoms patients express: difficulty reading, difficulty multitasking, and anything from mild cognitive difficulties to the loss of cognitive independence,” she said. “There is no research equivalent to the anecdotal symptoms that drive patient worries. Merging these two worlds is an important next step for the field.”
Reassuring the patient
Distilling all this information can, of course, make the patient feel anxious. Session presenter Miles Berger, MD, PhD, Professor of Anesthesiology, Perioperative, and Pain Medicine at Stanford University in California, said the best way to approach patients depends on several factors.
“How I would answer these questions depends to a large extent on where the patient and family are coming from when they ask these questions,” he said. “How anxious are they? How well-informed are they about this topic already? What is their degree of health/medical background and knowledge?”
Regardless of the patient’s background, Dr. Berger said gentle reassurance can go a long way toward easing their anxiety about postoperative neurocognitive decline.
“I often say that if a patient (or their family) feels really anxious about them developing postoperative delirium after surgery, I try to reassure them that delirium is a transient syndrome and, for most people, their thinking and cognitive abilities will usually clear up in the weeks following a delirium episode,” he said.
