A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
During the course of our careers as physicians, we have cared for or are aware of an elderly patient in the intensive care unit or ward who has exhibited delirium, or an acute confused state. This is particularly common after surgery and anesthesia. While simply being in the hospital can lead to delirium, several questions remain. Have best practices and guidelines been fully implemented to decrease this risk? Are clinicians continuing to administer drugs to elderly patients and those with mild cognitive impairment that are known to increase the risk of delirium?
Moreover, after these elderly patients return home from the hospital, we have all heard the stories of friends and family members who are not quite “the same” from the perspective of cognitive functioning. This phenomenon usually resolves over days, but can sometimes linger for weeks and even months, threatening the patient’s well-being and return to independence. Accumulated evidence suggests that postoperative cognitive disorders are the single most common side effect of surgical care in the elderly. In fact, postoperative delirium can occur in up to 70 percent of patients depending on the surgery and if multiple diseases or conditions are present. This condition is likely related to the stress of hospitalization, surgery, and anesthesia, especially in a patient who already has mild cognitive impairment.
Even when impairment is well compensated, these stresses can unmask and perhaps even enhance cognitive impairment. This apparent acute decline then becomes evident to those around them. As physician anesthesiologists, one of us has received repeated communications from patients who have experienced this, or are worried about themselves or their family members who are scheduled to have surgery, wanting to know if there is a “best” anesthetic for their brain. It has been estimated that 40 percent of postoperative delirium cases can be prevented. We in the medical community are now pondering ways to minimize these cognitive changes or hasten the patient’s return to baseline. This has culminated in a frank discussion with members outside of the medical community who also work with the elderly population.
We believe there is now some evidence for specific strategies to improve postoperative cognitive outcomes, and that we should be informing patients and providers about the risk as well as these strategies. In order to obtain traction on this issue the American Society of Anesthesiologists (ASA) convened a multi-stakeholder group including specialty societies who care for elderly patients undergoing surgery (e.g., American College of Surgeons, American Association of Orthopedic Surgeons, American Geriatric Society); payers (e.g., Centers for Medicare & Medicaid Services, Veterans Affairs); public advocacy groups (e.g., AARP, Institute for Healthcare Improvement); and federal funders (e.g., National Institute of Aging, Patient-Centered Outcomes Research Institute) under the umbrella of a Perioperative Brain Health Initiative. The group consensus agreed that the public should be made aware of the current state of evidence regarding perioperative brain health to aid decision-making and to improve outcomes for patients and their caregivers. In order for health care providers to be ready to answer questions from patients, we need to focus on perioperative health care provider education which highlights recommendations from the American Geriatric Society’s guidelines and the American College of Surgeon’s Coalition for Quality in Geriatric Surgery’s recommendations. These include recommendations for 1) tools for simple preoperative screening for cognitive impairment and risk factors including past history of confusion or disorientation, 2) checklists covering risk factors and the promotion of orientation through hearing aids, glasses, importance of family/ friends’ bedside presence and reassurance and 3) educating anesthesia providers regarding perioperative anesthetic sedative and analgesic drug choices, including medications to be avoided in those at risk.
We believe that such an initiative might encourage patients, their families and caregivers to disclose even subtle cognitive symptoms to surgeons and physician anesthesiologists preoperatively, at a time when providers can relay information on the potential benefits of “prehabilitation,” such as exercise, sleep, and nutrition. Patients should also ask surgeons, physician anesthesiologists and nurses if their hospital deploys strategies to reduce postoperative delirium and improve brain health, such as rapid mobilization and orientation. Orientation includes encouraging the family to bring familiar items to the hospital such as photos or other meaningful objects.
Delirium and cognitive changes after surgery and anesthesia are a major problem from both the perspective of patient care as well as its association with increased costs and complications. There is clearly a paucity of evidence both on how to implement the information we know, as well as gaps in knowledge for best practices with regard to perioperative brain health. Nevertheless, we believe there is sufficient early evidence to begin educating patients and providers.
Lee A. Fleisher and Roderic G. Eckenhoff are anesthesiologists.
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