Surgery Can Pose High Risk of Harm to the Brains of Older Adults:
A Guide to the Risk, Choices, Prevention, and Caregiving
Based on a Research Review of Over 150 Studies on Perioperative Neurocognitive Disorders (PND)
June 2024
Lynn W. Brallier, PhD, MSN
Healthcare Researcher and Evidence-based Clinician
Contents
- THE SERIOUS PND HEALTHCARE PROBLEM (pg. 1)
- PURPOSES OF THIS REPORT (pg. 1)
- THE SEARCH FOR SOLUTIONS TO PND (pg. 2)
- A Leading Geriatric Health Care Journalist
- Two Trustworthy PND Information Web Sites
- USING PubMed: ACCURATE PND INFORMATION (pg. 2)
- FOUR STAGES OF CARE FOR PND (pg. 3)
- Preoperative Care
- Intraoperative Care
- Postoperative Care
- Post Discharge Care
- ADVOCACY: FAILURE TO WARN OF PND (pg. 4)
- SUMMARY (pg. 5)
- ABOUT THE AUTHOR (pg. 6)
THE SERIOUS PND HEALTHCARE PROBLEM
Are you an older adult who is considering elective surgery? If maintaining your cognitive ability is a high priority for you, it is definitely in your best interest to be well-informed about the important brain health risk factors to consider as you make your decision. Many people, including healthcare professionals, are unaware of the long-known medical fact that adults over age 65 are at particularly high-risk of suDering from a spectrum of stressful and serious brain-changing perioperative neurocognitive disorders (PND) following anesthesia and surgery. Since so many older adults have never received information about PND from their favorite media sources or from their primary care provider, they may not take seriously the ethically responsible warnings given to them just prior to a proposed surgery. They may even ignore warnings from their own trusted geriatric nurse practitioner, geriatrician, or other primary care professional who knows them well and regularly witnesses notable or even devastating PND eDects on their patients’ emotional and cognitive capacities when preoperative cautions go unheeded.
If you spend time with older adults, you hear the frequently expressed fear of “losing it” as they observe their own behavior or that of others their age. You may also recall occasions in which an older person was “never quite right” or had to be placed in a memory care unit or nursing home following surgery. Though you may not have known that PND is the diagnostic term for the most likely cause of what you witnessed, you may have felt certain that something about their surgery had triggered deterioration of the person’s brain functioning.
Few older adults feel in need of another worry about a threat to their health. But those who are best at managing stress realize that squarely facing a possible huge challenge and learning about potential help for coping with or possibly avoiding it beats the alternative of being caught oD guard and profoundly shocked by its harm. Avoiders, despite having access to PND facts, may react with denial, calling the information false or believing it won’t happen to them or simply employing a “whatever” dismissive reaction. Those who care for older adults note that many are focused on the number of years they hope to live. When longevity is their goal, being faced with chemotherapy or surgical risks leads to an eagerness to comply with whatever an oncologist or surgeon is prescribing as possibly life extending with no serious consideration of possible tragic outcomes. They proceed as if believing that the treatment simply must be done and if they do what the doctor says, they will add more years to their life. But in what condition?
Postoperative Neurocognitive Disorders (PND) replaces the older term, Postoperative Cognitive Dysfunction (POCD). The diagnostic categories of PND include the immediately evident and seriously distressing postoperative delirium (POD), postoperative neurocognitive disorder (NCD), and longer lasting mild or major delayed neurocognitive disorder (DNR). All these types of PND are common in older adults postoperatively and some can cause prolonged recovery times, the serious suDering for everyone of long-term brain disorders like dementia, and huge costs of often frighteningly poor care if placed in a nursing home. PND’s also are significant contributors to other morbidities and to the mortality rate for older adults.
Many research experts estimate that some form of PND ranging from mild and transient to major and debilitating occurs in up to 65% of the older adult population after surgery. Others note that accurate acknowledgement of the number of PND occurrences is too low. Many older adults are embarrassed by their postoperative cognitive and emotional diDiculties and don’t want to worry others, so may spend more time alone and try to hide their experiences from others and even from themselves, telling people who may ask about their mental state that they are fine and changing the subject. Also, those involved with the postoperative patients may put aside their own observations of changes and, not wanting to embarrass the older adult, simply take them at their word if they are saying they are fine. Some care partners deny the PND symptoms they see by thinking of times they have forgotten something and deciding the changes they are observing in the postoperative person are just what happens as one ages rather than PND.
Care partners are not professionally trained to classify the details involved in determining neurocognitive status just prior to and again after surgery, so they cannot be expected to identify the sometimes-subtle behavior patterns that reflect a larger problem the older adult is well aware of but not talking about. Long-standing data gathered from people who have suDered milder forms of brain injuries make clear the many diDiculties they have that are not noticed by family and friends who keep extending congratulations to them for being well. Any health professional who is known to be a trustworthy listener is familiar with a patient sharing their PND truth that starts with, “Ever since my surgery…” and proceeds with reporting embarrassing diDiculties with word searching, memory, mood, and other brain functions that cause some withdrawal from conversations, “But everybody around me just tells me they don’t see me as having these problems. I feel so alone.”
Another powerful and particularly unfortunate source of denial of PND outcomes is surgeons and their staD who had probably failed to assess neurocognitive status and risk prior to performing surgery and also fail to diagnose neurocognitive deterioration in follow up surgical appointments. Usually these are brief and focused on wound healing, so patients are never asked about nor tested for PND symptoms. Surgeons, then, often deny that their patients suffered and continue to suffer some form of PND. This lack of responsible postoperative inquiry and diagnosis of PND means that a vast number of patients who suffer from a type of PND is not being properly noted and reported by hospitals and surgical centers, making accurate public health data unavailable to researchers for compilation. It also means that the true extent and seriousness of PND is not available to public media sources, preventing them from properly warning the public. Because so many PND cases are diagnosed after postoperative appointments have ended or were never reported as cases of PND to public health officials, you can see why many researchers have estimated that the likely actual incidence of some degree of PND ranging from very short-term mild to longer-term disabling may be closer to nearly all older surgical patients. Analysis of the large array of possibilities points to the hypothesis that while an outcome of no significant postoperative harm for any given patient is certainly possible, it is unlikely that there would be absolutely no harm at all to an older adult patient. Whatever the exact number, PND cases are common enough to have become a valid public health concern.
What causes these neurocognitive disorders that are especially frequent among older adults? It’s complicated. Our brains are constructed of many billions of fragile cells and thousands of kinds of cells, so there are no quick answers presently available, but many global research studies are ongoing. Numerous probable causes of PND and their interactive eDects preoperatively, during, and just after surgery are being investigated. So far, advanced age and neurocognitive decline that is evident prior to surgery are known to be important causal factors. In older adults the blood-brain barrier, a web of tissue that protects the brain from harmful substances in the bloodstream, may have become thinned and weakened so is less able to be an eDective barrier to the significant quantity of inflammatory substances in the blood that are produced by surgical wounding, anesthesia, and postoperative pain control drugs. The result is neuroinflammation, the inflammation that harms brain cells and their synaptic connections with one another causing PND. Longer time of surgery and surgeries that are highly tissue-wounding produce more inflammation that enters the brain. More on possible causes later.
Fortunately, the immediate postoperative experience of delirium may resolve fairly quickly and no other later types of PND occur for those who had remarkable preoperative cognitive reserve and/or very few risk factors other than age. However, some types all too often culminate in only partial recovery or become permanent, leading to a notable, even drastic decline in both quality of life and ability to care for oneself. This decline so often leads to the undesired but necessary placement in a care facility. That postoperative option is one very few adults want for themselves or their loved ones after surgery considering the frequency of investigative reports that reveal the understanding, neglect, rape, and other psychological and physical abuses that have been documented to occur in some of these kinds of facilities. Polls keep indicating that over one-half of middle-aged and older people say they would rather die than be placed in a nursing home. Cardiologists are familiar with being told by many of their older patients who need surgery that they would rather die on the table than come out of surgery disabled, dependent, and no longer able to care for themselves. Care partners of people unable to stay in their own homes witness their loved ones experience searing grief and understandable depression upon losing the familiar comforts and precious embedded memories of life in their home that includes long-term close relationships with neighborhood friends. Statements from those who are experiencing PND and from those who were close to someone both prior to and after surgery, offer extraordinary insight to the rest of us. On April 24, 2022, UK-based news source, The Guardian, published online a neuroscience report by Dr. David Cox entitled, “The hidden long-term risks of surgery: ‘It gives people’s brains a hard time.” Four US researchers then conducted an inductive qualitive thematic analysis of the online replies to that Guardian report. On March 1, 2023, they published among research studies. To address this serious barrier to progress, a multispecialty global group of experts formed The Nomenclature Consensus Working Group and published their recommendations for the nomenclature of cognitive change associated with anesthesia and surgery on June 15, 2018, in the British Journal of Anesthesia. Hopefully, the new standardized terminology will be widely adopted by researchers, allowing valid, reliable comparisons of data to inform preventive and postoperative treatment plans for patients. The 2018 nomenclature terms are included in this paper and listed for use later in the research sections as Keywords.
PURPOSES OF THIS REPORT
This report of results from a research review of over 150 studies addresses four broad purposes. It will continue to offer its reader-friendly holistic view of the many relevant interactive parts of PND facts and issues. This whole-picture approach by necessity includes data from both quantitative experimental studies and qualitative studies that gathered in-depth data about the lived experiences of PND from those diagnosed with one or more forms of it. Results from both quantitative and qualitative studies are presented here in an unusually simplified summary form. It is designed for older adults who are not healthcare professionals and for the healthcare professionals caring for them who may want an easy overview of PND issues that may be encountered. Summary form means that several studies must report similar results for that data to be included in this review report. This simpler way of reporting the major agreed-upon results to you avoids citation of individual studies as one would for publication in a research journal.
The second purpose is to help you be aware of the search for PND solutions and learn easy ways to do some searches yourself to update information whenever you need to by visiting excellent websites and by using keywords on the PubMed research site relevant to your situation. The studies that informed the results reported here and new studies similar to them can be found by using specific keywords oDered to you in each section of this paper. Simple directions are given for utilizing keywords to find the information most relevant to your needs. This keyword-only format, rather than notation of each study reviewed by the author, allows easy retrieval of whatever content you choose to update at any time.
The third purpose of this holistically oriented paper is to offer details of PND care. This includes information on how to get help with determining your personal health risk for PND that includes the risk presented by the type of surgery being considered. The additional sections offer details on intraoperative, postoperative, and post discharge care that are important for yourself and your care partners to know as a guide for planning care if you choose to have surgery.
Last, this paper serves as an advocate on behalf of older adults, making the case for them to be recipients of informed, respectful, and thoughtful perioperative care. It poses an ethical challenge to surgeons, anesthesiologists, nurses, and all other healthcare professionals treating older adults to be well informed of the latest PND research and able to initiate unbiased shared decision-making conversations about the PND risks to brain function posed by the combination of personal and surgical procedure risk factors. While acknowledging that conducting an adequate PND risk assessment process takes talent, skill, and clinical time that may not be billable, this paper supports the ethical position that health care professionals must accomplish it. No patient should ever suffer the drastic shocking consequences of failing to have been adequately warned about their personal PND risk. There are many research papers and consultants available to guide the risk assessment process toward being swift and successful, allowing the usual basic clinical care requirements of respectful listening, caring, protecting from harm, and ethically advising treatment options for the surgical candidate. Concordant care finds consensus between surgical candidate and health professionals when discussing the proposed surgery, treatment alternatives to surgery, less traumatic surgical approaches, and the outcomes of choosing to delay or decline the surgery if risk factors for PND are perilously high.
[To read a summary of this paper before proceeding to the next sections, go to Summary on Page 5.]