Vince
Super Moderator
A number of studies have indicated that surgery in the elderly is a risk factor for, and perhaps a cause of, accelerated cognitive decline. Anesthesia may play a role in this, although the issue remains controversial.
We contacted several surgeons and anesthesiologists via e-mail to ask:
Do you agree that surgery is a risk factor and/or potential cause of cognitive decline in the elderly?
To what extent should this risk be discussed with patients and their families?
Where in the consent process should this be introduced: with the surgeon or with the anesthesiologist?
The participants this week are:
Richard J. Shemin, MD, Robert and Kelly Day Professor at the David Geffen UCLA School of Medicine and chief, cardiac surgery at the Ronald Reagan UCLA Medical Center
Timothy J. Gardner, MD, medical director, Center for Heart and Vascular Health and executive director, Value Institute at Christiana Care Health System in Newark, Del.
Michael L. Schmitz, MD, professor, anesthesiology and director, cardiovascular anesthesia at the University of Arkansas for Medical Sciences in Little Rock
Reality in an Aging Population
Richard Shemin, MD: Cognitive dysfunction in the elderly after major surgery is a reality, but is variable in degree and duration from one patient to another. As a cardiac surgeon, I monitor the brain carefully during the operation and employ best practices preop, intraop, and postop to minimize adverse brain events. The aging population will require surgeons and all providers of perioperative services to study the causes and advance the knowledge base on neurocognitive decline to achieve improved safety and outcomes for elderly patients. Most patients do very well. However the harder we look, the more brain dysfunction can be found. I predict that new advances will be on the horizon.
Timothy Gardner, MD: Major invasive surgical procedures that require general anesthesia pose a greater risk of stroke and neurological injury for elderly and frail individuals compared with younger persons. For any surgical procedure or complex medical treatment especially in advanced elderly persons who face a life-threatening condition, the risk of treatment-related death and neurological injury should be fully understood and carefully considered by the patient and family before the procedure.
Michael Schmitz, MD: Yes, there are perioperative factors that place some elderly patients at risk for postoperative cognitive dysfunction -- physicians have observed this inconsistent finding for over 60 years. What those factors are, what characteristics make some elderly patients more susceptible, and why the severity of this disorder is so variable are questions that will take well-designed, large-scale research efforts to answer.
A 'Reasonable' Discussion
Gardner: The stroke and neurological injury risk must be discussed with the patient and family. For most surgical operations, we have information from experience, reports, and published studies that allow us to provide an accurate estimate of some risks, i.e. "the risk of stroke for this procedure for someone your age is around 4% based on reports and our own experience..." It is more difficult to predict the risk of cognitive decline since it does not manifest as a specific event or change like a stroke, but may only be evident weeks, months, or years after surgery.
Shemin: The neurological risk should be discussed with all patients and their families in every case. In my practice, this is routine. The risk in cardiac surgery can be calculated from our database for each procedure based on well known risk factors.
The Consent Procedure
Schmitz: Given that we are not certain what causes postoperative cognitive dysfunction, how often it occurs, how to predict its severity, how long it might last, and have nothing really yet to mitigate the risk (other than not to proceed), a brief inclusion in the consent process seems reasonable. POCD is a perioperative risk as best as we can define presently and my opinion is that it should be included in those consents by perioperative physicians, including surgeons and anesthesiologists. Quite possibly, there may be patients who would re-evaluate their need for purely elective surgical procedures.
Shemin: These risks should be the surgeon's responsibility during the consultation and prior to the informed consent.
Gardner: The surgeon clearly is primarily responsible for obtaining informed consent prior to an operation, including an appropriate discussion about the risks of stroke and neurological injury. http://www.medpagetoday.com/Surgery/GeneralSurgery/55188
We contacted several surgeons and anesthesiologists via e-mail to ask:
Do you agree that surgery is a risk factor and/or potential cause of cognitive decline in the elderly?
To what extent should this risk be discussed with patients and their families?
Where in the consent process should this be introduced: with the surgeon or with the anesthesiologist?
The participants this week are:
Richard J. Shemin, MD, Robert and Kelly Day Professor at the David Geffen UCLA School of Medicine and chief, cardiac surgery at the Ronald Reagan UCLA Medical Center
Timothy J. Gardner, MD, medical director, Center for Heart and Vascular Health and executive director, Value Institute at Christiana Care Health System in Newark, Del.
Michael L. Schmitz, MD, professor, anesthesiology and director, cardiovascular anesthesia at the University of Arkansas for Medical Sciences in Little Rock
Reality in an Aging Population
Richard Shemin, MD: Cognitive dysfunction in the elderly after major surgery is a reality, but is variable in degree and duration from one patient to another. As a cardiac surgeon, I monitor the brain carefully during the operation and employ best practices preop, intraop, and postop to minimize adverse brain events. The aging population will require surgeons and all providers of perioperative services to study the causes and advance the knowledge base on neurocognitive decline to achieve improved safety and outcomes for elderly patients. Most patients do very well. However the harder we look, the more brain dysfunction can be found. I predict that new advances will be on the horizon.
Timothy Gardner, MD: Major invasive surgical procedures that require general anesthesia pose a greater risk of stroke and neurological injury for elderly and frail individuals compared with younger persons. For any surgical procedure or complex medical treatment especially in advanced elderly persons who face a life-threatening condition, the risk of treatment-related death and neurological injury should be fully understood and carefully considered by the patient and family before the procedure.
Michael Schmitz, MD: Yes, there are perioperative factors that place some elderly patients at risk for postoperative cognitive dysfunction -- physicians have observed this inconsistent finding for over 60 years. What those factors are, what characteristics make some elderly patients more susceptible, and why the severity of this disorder is so variable are questions that will take well-designed, large-scale research efforts to answer.
A 'Reasonable' Discussion
Gardner: The stroke and neurological injury risk must be discussed with the patient and family. For most surgical operations, we have information from experience, reports, and published studies that allow us to provide an accurate estimate of some risks, i.e. "the risk of stroke for this procedure for someone your age is around 4% based on reports and our own experience..." It is more difficult to predict the risk of cognitive decline since it does not manifest as a specific event or change like a stroke, but may only be evident weeks, months, or years after surgery.
Shemin: The neurological risk should be discussed with all patients and their families in every case. In my practice, this is routine. The risk in cardiac surgery can be calculated from our database for each procedure based on well known risk factors.
The Consent Procedure
Schmitz: Given that we are not certain what causes postoperative cognitive dysfunction, how often it occurs, how to predict its severity, how long it might last, and have nothing really yet to mitigate the risk (other than not to proceed), a brief inclusion in the consent process seems reasonable. POCD is a perioperative risk as best as we can define presently and my opinion is that it should be included in those consents by perioperative physicians, including surgeons and anesthesiologists. Quite possibly, there may be patients who would re-evaluate their need for purely elective surgical procedures.
Shemin: These risks should be the surgeon's responsibility during the consultation and prior to the informed consent.
Gardner: The surgeon clearly is primarily responsible for obtaining informed consent prior to an operation, including an appropriate discussion about the risks of stroke and neurological injury. http://www.medpagetoday.com/Surgery/GeneralSurgery/55188
