Anesthesiology as a profession has made significant contributions and improvement towards understanding and managing perioperative brain health of elderly patients. As such, we anesthesiologists are uniquely positioned to take a leading role in better educating our medical colleagues – primary care physicians in particular – on what we now know about the risks to brain health our elderly patients may face. Here’s some key information to pass along. By Dr. Zulfiqar Ahmed, M.D. F.A.A.P.
Typical factors that can affect the brain health of elderly patients at the time of operation and/or anesthetic include age, pre-existing neurocognitive deficits, and type of operation and/or anesthetic, among many others. For some patients, there is another factor that should be included in this list: perioperative neurocognitive dysfunction (PND), now better understood due to multi-disciplinary initiatives to study the long-term effects of the operation on the patient’s brain health. According to research, we now know that the incidence of PND is higher than most other perioperative complications.
American Society of Anesthesiologists’ perioperative working group on neurotoxicity has issued a consensus statement that, “All patients over age 65 should be informed of the risks of PND including confusion, inattention, and memory problems after having an operation.” There are three good reasons for this.
- Alerting patients to the risks of PND gives them and their families a realistic impression of their possible postoperative recovery course, and what their cognitive state may be in the days, weeks, and months after anesthesia and surgery.
- Educating patients about these risks can allow patients to plan effectively so they can either make important cognitively demanding decisions before anesthesia and surgery or delay making these decisions until several months afterward.
- Informing patients of these risks could help facilitate planning for measures to mitigate the risk of PND, such as encouraging family engagement and promoting early mobility.
Primary care physicians, for their part, must consider their elderly patients (65 and older) for the presence of pre-operative cognitive dysfunction the same as they would a dysfunction in another major organ system.
Preoperative cognitive impairment is a strong preexisting risk factor for PND, so assessing baseline cognitive function before surgery could help allow patient stratification for PND risk so that resources and interventions (such as intraoperative protocols to prevent PND) can be targeted at high-risk patients, similar to the way anesthesiologists stratify patients based on the function of other organ systems.
In addition, identifying patients with preoperative cognitive impairment could also help target these high-risk patients for interventions to minimize PND. Such interventions might include improvement of sleep and nutrition hygiene, avoidance of specific drugs, specific intraoperative management strategies31 (see below), rapid return of glasses and hearing aids, and family engagement and orientation strategies. Identifying at-risk patients for these targeted interventions may reduce the risk of PND by up to 40%.
At present 3D-CAM is the validated tested method of cognitive evaluation which is easy to administer and need little training. The current available cognitive tests for evaluation of pre-operative cognitive deficits are many, and of variable sensitivity and specificity. They include CODEX (Cognitive Disorder Examination), MMSE (Mini-Mental State Examination), MoCA (Montreal Cognitive Assessment), Minicog, Clock drawing test, and verbal fluency test. If you suspect that your patient is at risk for PND then you may consider pre-operative cognitive testing in a way of your choice.
Armed with this information, primary care physicians will be better equipped to adequately plan for elderly patients’ perioperative care, from in-depth discussion with the patient and family to cognitive evaluation and post-op follow-up. As anesthesiologists, we have a duty to share this information with our medical colleagues.
Ed. Note: This post is based on an open letter written by Dr. Ahmed on behalf of the quality committee of Siromed/Anesthesia Associates of Ann Arbor (A4). A version of that letter was first published in the newsletter of St. Joseph Mercy Health System in Michigan.