Dear Physicians,
We, as the anesthesiologists taking care of your patients at the health system, want to communicate with you about an important health care challenge your elderly patients may be facing. Recent data has shown that the incidence of peri-operative neurocognitive dysfunction (PND) is higher than any other peri-operative complication. There are various factors influencing PND including age, pre-existing neurocognitive deficits, type of operation and/or anesthetic medications among many other factors.
American Society of Anesthesiology’s 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.”
Preoperative cognitive impairment is a strong, preexisting risk factor for PND, hence assessing baseline cognitive function before surgery could help allow patient stratification 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. Hence, we recommend that you screen your patients above 65 years of age for the presence of pre-operative cognitive impairment. There are three reasons to do so. First, if cognitive dysfunction is found on assessment, your patient may choose to make important decisions before anesthesia and surgery as well as help prioritize various responsibilities. Second, informing patients and their families of the risk of PND can help them to collectively engage with the patient and encourage early mobility; actions which we know help to mitigate PND. Third, by discussing this pre-operative concern, the patient is better educated to understand and anticipate the post-operative course.
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, avoidance of specific drugs, rapid return of glasses and hearing aids, and family engagement and orientation strategies. Identifying at-risk patients for these interventions may reduce the risk of PND by up to 40%.
The current available cognitive tests for evaluation of pre-operative cognitive deficits are many and of variable sensitivity and specificity but the 3D-CAM is a simple test with a high degree of reliability. It has been validated for use in assessing cognitive dysfunction and would serve as a valuable baseline prior to your patients surgery. Please click on the following links for further reading about the anesthesiologist’s perspective or updated research on brain aging.
Sincerely,
Dr. Traci Coffman, President of A4 (https://a4anesthesia.com/)
Opioid-Free Care
