One of the most heartbreaking moments of my career as an anesthesiologist came when I met the man I’ll call Mr. D. He was in his mid-eighties, but little about him suggested that old age had slowed him down: he was a witty conversationalist and an avid reader, a recently retired newspaper editor who could still attack the most difficult crossword puzzles with glee. Before he went in for surgery, he pulled me aside and asked me a question. He was fairly certain, he said, that his body will recover, but he wanted to know if he might experience any cognitive side effects like forgetfulness or confusion. I said it was possible and promised to visit him the next day, after his procedure. When I did, I saw this elegant and graceful man sitting on his bed, staring at the electric shaver he had brought with him from home. He was trying to figure out what it was.
Mr. D is hardly the only one to grapple with this distressing condition. Some patients experience delirium, which typically occurs in the first few days after surgery, during which they feel an acute onset of waxing and waning attention along with confusion and generalized cognitive dysfunction. Most cases of post-operative cognitive impairment resolve, but others may linger, placing patients at increased risk of mortality, loss of independence and motor functions, and lengthier hospital stays. For ambulatory patients, the risks are relatively low—only four to seven percent experience cognitive dysfunction after surgery. For emergency or other more invasive procedures—anything related to the chest, heart, or lungs—risk of delirium is much higher, with up to two-thirds of all patients affected.
Why does this phenomenon occur? And how may we treat it? The truth is that we’re not sure. It’s a question anesthesiologists like myself have been studying for over a decade now: Why may two 80-year-olds with similar health profiles come in and undergo the same surgery and yet one suffers from delirium and the other does not?
At first, researchers looked at general anesthesia versus epidural or regional techniques, hypothesizing that the kind of anesthesia a patient received may have something to do with his or her ability to cognitively rebound. That, as it turned out, wasn’t the case: rates of delirium were the same for both methods. Studying the phenomenon further, scientists now believe that it is multifactorial. Inflammation likely plays a very important role, and researchers continue to investigate risk associated with specific surgical procedures and medications, in addition to patient-specific factors. For example, existing cognitive conditions, which a lot of elderly patients have, may have an impact on risk as well.
What, then, might we do to help patients recover? First, it will help to have an idea of their cognitive capacity before the surgery. If we make a simple test a part of the pre-op procedure, we’ll be able to tell if their baseline has changed, and if the patient is experiencing cognitive alteration. The patient’s post-op environment is critical as well: if we make sure patients are hydrated, have their glasses or hearing aides, and occupy hospital rooms that allow them to maintain normal sleep cycles—which may mean not waking them up in the middle of the night to check their vitals—we may decrease their chance of developing delirium.
As physicians and researchers, we have our work cut out for us but our patients do as well. If you’re having surgery and have time to prepare, you may want to quit smoking, limit alcohol, engage in meaningful cognitive exercise—such as reading or social activities— and get plenty of physical exercise, if you are able. Remember that brain health is body health, and you should optimize your brain as you would any other organ.
This piece is part of a special brain health initiative curated by Dr. Ali Rezai, Director of Ohio State University Wexner Medical Center’s Stanley D. and Joan H. Ross Center for Brain Health and Performance. For more, visit The Huffington Post’s Brain Health page.
