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When Surgery Disrupts Your Focus And Memory

Feeling “loopy” or “out of it” for a couple of days after surgery is “super common and generally resolves pretty quickly,” says Richard Anderson, MD, a Premier Health anesthesiologist and medical director of perioperative services at Miami Valley Hospital South. Postoperative delirium is the formal name for this post-surgery fog.

But another condition, postoperative cognitive dysfunction or decline (POCD), can have more lasting effects on memory, attention, and concentration – from months to a lifetime. First described about a century ago, POCD has relatively recently become the subject of more intense medical study, Dr. Anderson says.

“There’s never been an agreed-upon diagnostic criteria for POCD, and it’s not routinely screened for,” he explains. But that’s changing.

Why? First, people over age 60 are two times more likely to encounter POCD than younger surgery patients.

“We have such an aging population now, that the proportion of patients who experience POCD, or are at risk for it, is just going to skyrocket over the next decade.”

Dr. Anderson adds, “Patients are very interested in POCD now. The more educated patients get and the more they read about it in the popular media, they are starting to ask about it.”

And the medical community is beginning to better define and understand the condition. The American Society of Anesthesiologists launched the Perioperative Brain Health Initiative, primarily to focus on POCD. Dr. Anderson says the initiative is addressing questions such as:

• How are we going to screen patients (for POCD risks) before surgery?
• Who is at risk?
• What are we going to do about it in terms of anesthesia technique?
• And how do we follow patients after surgery?

Who Is At Risk Of POCD?

Besides age, other factors that increase patients’ risk of POCD include:

• Preexisting cognitive issues, such as mild cognitive impairment (MCI) or dementia. MCI is a transitional phase between normal mental function and Alzheimer's disease or other forms of dementia.
• Medical conditions such as diabetes or cerebrovascular disease, which reduces blood flow and oxygen to the brain and increases the risk of stroke
• Lower education levels or lower IQ scores
• A low preoperative vitamin D level (though there is some debate about this, Dr. Anderson says)

POCD risk also varies by type, complexity, and length of surgery. Dr. Anderson explains:

• “Cardiac surgery seems to be one of the highest risk surgeries. As high as 40 percent can have postoperative cognitive decline.” The age of patients most commonly having cardiac surgery contributes to this elevated risk level.
• “As the complexity and the length of surgery goes up, so does the risk of postoperative cognitive decline. A knee scope (arthroscopic surgery) has relatively minimal risk compared to a six-hour abdominal surgery, for example.”
• “Trauma and surgeries associated with trauma, such as hip fractures and car accidents, tremendously increase your risk.”

People over age 60 are two times more likely to encounter POCD than younger surgery patients.

What Are the Symptoms Of POCD?

Common symptoms of POCD include problems with memory, attention, and concentration, from months to a lifetime after surgery. For instance:

• Difficulty remembering recent happenings
• Insufficient ability to concentrate on reading a book or newspaper
• Reduced ability to perform arithmetic

Also, people with POCD easily become tired.

How Can POCD Risk Be Controlled?

A variety of strategies may help control your risk for POCD before, during, and after surgery, Dr. Anderson says.

• Controlling preexisting conditions: Most preexisting risk factors, like age and education level, can’t be controlled before an operation. But Dr. Anderson says you can have a favorable effect on lowering your POCD risk by controlling symptoms of health conditions such as diabetes, heart failure, and blood pressure.
• Screening for mild cognitive impairment: A random pre-surgery screening test could identify patients who have preexisting mild cognitive impairment, Dr. Anderson suggests. “I think over time, those with preexisting cognitive issues are the ones who are really at risk for issues after surgery. If we routinely screen, we’ll be pretty good at picking up those who are at risk.”
• Planning anesthesia: Dr. Anderson recommends talking with your anesthesiologist before surgery. Considering your risk factors for POCD, the anesthesiologist may be able to change how your anesthesia is managed during surgery. “Regional anesthesia, meaning spinals, epidurals, or nerve blocks, are probably better than general anesthesia” for limiting POCD risk.
  
  Dr. Anderson adds, “The more we can avoid narcotics and long-acting sedative medications, we are probably protecting patients from postoperative cognitive decline."

• Monitoring during surgery: “When we’re in the operating room, paying close attention to vital signs — in particular blood pressure — probably has a protective effect,” Dr. Anderson says.
  
  He adds that a brain anesthesia monitor helps the anesthesiologist keep watch on the patient to prevent providing the patient more anesthesia than necessary.
  
  Sharing with your health care provider any cognitive changes you experience following surgery also can be helpful.

“If we combine all of these small factors, we have a decent chance of preventing or at least reducing the POCD burden,” Dr. Anderson concludes.

Sources: Richard Anderson, MD, medical director of perioperative services, Miami Valley Hospital South; Association for the Advancement of Science; University of Rochester Medical Center; Society for Neuroscience in Anesthesiology and Critical Care; Anesthesia Web

Richard Anderson, MD

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