A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.
“I am so ashamed. I am truly sorry to anyone I hurt or offended.”
These were the first words Beverly said when I met her in the preoperative holding area before surgery. She was referring to her recent behavior during an episode of postoperative delirium. Beverly could barely make eye contact as she described how she didn’t remember anything she said, but her son and some of her health care providers had told her parts of the story. She had pulled out her lines, thrown them across the room, and accused health care providers of physically abusing her, screaming paranoid accusations at anyone who walked into her room. “Please don’t let that happen to me again,” Beverly begged me as we prepared to go back to the operating room for another washout of her infection.
Unfortunately, with her medical history, Beverly was at an elevated risk for developing postoperative delirium again. So, we talked together about postoperative delirium. I let her know that she was not alone and that postoperative delirium is common in older patients. We discussed that I would avoid administering medications that might increase the risk of delirium. We also discussed that her family could help reduce the risk by coming to visit and that she should ask to have her hearing aids and glasses right away to help her reorient to her environment.
This June, during Alzheimer’s and Brain Awareness Month, we want to empower health care professionals to promote brain health in the perioperative period. Here are two crucial steps to promote brain health before, during, and after surgery:
1. Education. Invite relevant stakeholders, including surgeons, geriatricians, hospitalists, and nurses, to learn more about perioperative cognitive disorders. Delirium and longer-lasting postoperative neurocognitive disorder after surgery and anesthesia are the most common complications in adults 65 and older undergoing surgery, and are associated with increased morbidity, departure from the workforce, decreased independence, and mortality. It is easier to implement best practices for delirium risk stratification, prevention, identification, and treatment with stakeholder buy-in. For example, risk stratification often includes a brief preoperative cognitive and frailty screening to identify patients at the highest risk.
2. Communication. It is essential for health care professionals to have conversations about perioperative brain health with at-risk patients and their loved ones and caregivers. Ideally, these conversations would first occur with the surgeon at the time the surgery is booked or during a preoperative anesthesia (or medicine) clinic visit. With enough time before surgery, patients can prepare to bring their hearing aids, glasses, and other assistive devices to the hospital. Family members can also be prepared to help promote sleep hygiene and keep calendars, clocks, and photos to help orient the patient after surgery. These conversations are much more productive when they occur preoperatively rather than when a family member hears the term “delirium” for the first time when the patient is delirious after surgery.
After Beverly was discharged from the hospital, we kept in touch. I had the opportunity to meet her adult son. He expressed how grateful he was to learn about postoperative delirium. His mom had several operations over the past few years, and unfortunately, this was not the first time this family had to witness her experience postoperative delirium. However, no one had ever explained to him that this was a common postoperative complication in older adults. He expressed that he and other family members had blamed his mother for her out-of-character behavior.
Anesthesiologists are proud to play an important role in preventing, identifying, and treating perioperative cognitive disorders like delirium. We ask other health care professionals to raise awareness of perioperative brain health by discussing postoperative delirium and other perioperative cognitive disorders with your colleagues, patients, their caregivers, and their loved ones. Tools and resources, such as clinical guides, key actions for care teams, and case studies can help you do just that.
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