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This is a holistic evidence-based clinical and public health research summary paper written for older adults, their care partners, and their healthcare professionals. Based on a formal research review of over 150 research studies on Perioperative Neurocognitive Disorders (PND), it offers information about essential conditions and procedures for receiving or offering ethical, patient-centered, evidence-based flow of care to older adults who may be at high risk for suffering serious forms of PND if they consent to anesthesia and surgery. The PND diagnostic categories are the immediately evident and seriously distressing postoperative delirium (POD), postoperative neurocognitive disorder (NCD), and longer lasting mild or major delayed neurocognitive disorder (DNR). Detailed information is offered about the care needed for each of these types of PND.
FIRST: PUBLIC EDUCATION IS NEEDED ABOUT PND THE KNOWN RISKS FOR IT
We must do much better public education about PND so people of all ages are aware of the very real PND risk posed by anesthesia and surgery for older adults. Being accurately informed allows them and their care partners to be aware of risk before surgery is even a possibility in their lives. Even though global medical research verifying the sad reality of PND as a frequent and major healthcare problem has been conducted for many years, most people, including too many health professionals, have never heard of it. Since there is so little media coverage of PND, a typical response by any age group of the public upon hearing about PND is to say with a bit of skepticism, “I’ve never heard of that—is it really a thing?” Yes it is.
This being the case, clinicians and researchers must do more to step up and provide current accurate information about PND risk as feature reports to radio and TV stations and other media sites favored by older adults. An older person and their care partner already aware of the possibility of PND can guide themselves through the preoperative decision making phase to make an informed decision rather than waking from surgery feeling stress and shock from harm to the brain that no one had warned them could happen. When postoperative delirium leads to a lasting serious neurocognitive decline and recovery is not possible, placement in a facility may be necessary, delivering serious anxiety and grief to someone who may have held the frequently stated position of elders that they would rather die than suffer institutional placement at a demented adult.
SECOND: A THOROUGH PREOPERATIVE RISK ASSESSMENT MUST BE CONDUCTED
This clinical risk assessment process is conducted by a health care team and includes a thorough physical, neurological, and psychological assessment to estimate the level of risk surgery poses to the person’s postoperative life. Though age is the primary high-risk factor for PND, testing for many others is imperative. Since evidence of dementia is another high risk, adequate testing is required for clarity regarding brain health and a thorough honest discussion follows to warn of what that risk could mean about likelihood of experiencing delirium and longer lasting forms of PND. Many other physical and brain health conditions that might interfere with the stability of oxygen and glucose to the brain during surgery are part of the assessment. All the personal high-risk factors then must be added to the risk level inherent in the type and length of anesthesia and surgery being proposed to estimate as accurately as possible the likelihood for delirium and other PND to occur for that person undergoing their particular surgery.
Some anesthesia and surgical departments view the time and expense of conducting a thorough preoperative risk assessment on surgical candidates as too high, while others have made efforts to streamline the process without sacrificing too much accuracy. It is also important to ask the person’s geriatric care provider or internist or other health professional who knows the person well for their insight regarding their patient’s neurocognitive health status and opinions that have been expressed to them by the patient about the proposed surgery.
THIRD: AN IN-DEPTH DISCUSSION OF RISK/BENEFIT IS ESSENTIAL, NOT OPTIONAL
After the risk assessments are finished, the anesthesiologist, surgeon, and all other perioperative team members whose knowledge is relevant to the risk level should meet with the prospective patient and their care partners to give them the best estimate possible of combined personal and surgical risks to the person’s general health and risk of PND to brain health. In this patient-centered meeting, a truthful estimate, especially if warning of high risk, must be presented. If the assessment has indicated that a warning of neurocognitive harm is required, discussion of details of what the experiences of delirium and other medium and longer term PND are usually like for the potential patient and care partners is next. Team members who have seen PND outcomes should be present to describe possibilities accurately and completely to protect those involved from the painful stress, shock, and upheaval of serious and unexpected adverse outcomes. Every effort must be made to deliver the most accurate warnings possible. Failing to warn is not only an ethical issue but a potential legal matter as well.
Obviously, making sure the surgical candidate and care partners have grasped the details of the risk assessment is essential. The meeting to discuss the results of PND risk versus benefits of surgery is a point of concordance at which no one involved should be assuming that the person must accept surgery as an absolute necessity for themselves until the risks and discussion of them is thorough, honest, and complete. The main topic to discuss centers on the surgical candidate’s answer to the questions, “What are the personal characteristics you most value about yourself?” and, “Which of your activities are most vital for you to continue after surgery?” Risks for PND then must be focused on the degree of risk surgery poses to seriously harming or destroying the essence of the surgical candidate’s identity.
FOURTH: EXPLORATION AND SUPPORT FOR CHOICES
This phase must be fully patient-centered rather than surgeon-centered so that declining surgery is an option that can be thoughtfully chosen in the risk/benefit discussion without feeling coerced in any way by the surgeon involved. If the risk of elective surgery is high to physical or neurocognitive health or to life itself, a landscape of choices should be discussed, so appropriate members of the team need to be present to contribute to that discussion. For instance, exploring whether there is a minimum surgery option that would mean less risk of exposure to the neuroinflammation of surgical trauma and the chemicals used for lengthy anesthesia and for pain management is very important. Is the current surgeon willing to offer that option or is another surgeon a better choice? Also, what about other treatments for the problem? Some people with high PND risk choose additional forms of pain management or new treatments being offered for the problem if it seems that surgery is likely to lead to no longer being fully themselves. When other older adults become aware of their high risk of PND for the surgery that offered some chance to live longer but means that future life could be as someone with PND who is requiring day care or is a resident of a nursing home, they wish to decline surgery in favor of a shorter life but as themselves. Anticipated discussion of these valid choices calls for geriatric, palliative care and even hospice professionals to be present for this session.
FIFTH: ASSISTANCE WITH PND AFTERCARE DECISIONS
Hopefully, some members of the original preoperative assessment team, especially geriatric care professionals, can offer guidance to patients and their care partners if delirium has continued to be problematic or has led to a longer-term form of PND. An evaluation of the type of PND and prognosis for resolution of it and the homecare able to be arranged is necessary with attention to care of the care partners who may be overwhelmed, severely stressed, lonely, and depressed. Some care partners may have to return to work and leave the person with PND unattended. In that case, help with determining options for day care or residential placement are necessary.