Evaluating the Association of Anesthesia, Surgery, and Cognitive Decline in Older Adults

Susana Vacas, MD, PhD

The aging population faces particular risk when undergoing surgery, with postoperative neurocognitive disorders (PNDs) at the forefront of concern for patients over the age of 65 years in need of these procedures. Modifiable and nonmodifiable risk factors, as well as aspects of patients’ baseline vulnerability, contribute to their potential development of PNDs, which can be mitigated through the integration of a perioperative care team.

Susana Vacas, MD, PhD, assistant professor of anesthesiology at the David Geffen School of Medicine, University of California–Los Angeles, sat down with NeurologyLive to discuss the rate of cognitive decline in these patients, noting the importance of preoperative initiatives to bolster resilience in older patients, particularly maintaining a healthy lifestyle, which can also help reduce risk for dementia.  

Vacas further discussed changing perspectives in health care, such as those about patients previously being instructed to leave necessary hearing or visual aids at home because of the risk of them being lost in the hospital setting. Although, it is now understood, she said, that patients should have these aids immediately available following movement to the recovery unit. Involving the family and support system can also be of assistance, in combination with the interdisciplinary health care team within a comprehensive system of care.

NeurologyLive: What prompted this article? Can you provide additional background and context?

Susana Vacas, MD, PhD: When I was a resident, I didn't understand that we were doing surgery and giving anesthesia to these patients [where] the outcome would be to improve their health or improve their lives, and then, throughout my training, I realized that some of these patients…they got their hip replaced, they had their surgery, but they were not feeling the same after surgery. There was this entity that we have been uncovering more and more about, and while the mechanisms are not known, the overarching term that we give is “perioperative neurocognitive disorders.” These can take several forms—one of them is delirium, which is [when], in the first 7 days after surgery, the patient goes into a confusional state of inattention and they don't really know where they are. Most of those patients recover. But what we've known is that among patients that are age 65 years and older, up to approximately 65% of the patients go [with] noncardiac anesthesia, [and] 10% develop this long-term cognitive decline. So, this prompted my research and prompted this article to be written to raise awareness for these issues.

What are the specific effects of anesthesia and accompanying surgery on postoperative neurocognitive disorders in older adults?

What we know now is that first, we estimated about 40% of the cognitive issues seen after surgery can be preventable. [This is] important in that the outcomes for these diseases lead to longer hospitalization. Actually, in older populations, it's been linked to an increased risk of mortality 1 year after surgery, and risk of premature leaving of work. 

We need to think about our patients and the burden, not only for the patients but the families that are taking care of these patients. One example that I give is, a patient that goes to [get] the groceries and no longer knows what's missing at home because they forget these little things, their daily activities. Also, delirium has—in terms of the hospital care and health care costs—been linked not only to, like I [said], increased days of hospitalization, but has also been linked to increased days of ventilation or ICU. It is estimated that the health care costs in the United States alone can reach up to $150 billion per year. 

What are the gaps in communication both pre- and post-care? How can multidisciplinary management of these patients assist in the level of care provided?

We were talking a little bit about the risk factors for this disease, and there are ones that are nonmodifiable. We talked about age, but also other risk factors, such as the invasiveness of surgery, or if it's elective, and also the optimization of the patients before surgery. This is where we want to raise awareness—that the surgeons and anesthesiologists should assess, discuss, and optimize potential risks for each patient, and it has to occur before surgery. The best practices and interventions can start and begin way before the surgery and then extend into the recovery period. 

To be most effective, these strategies require family engagement and involvement of this interdisciplinary health care team. One example is the family and support system—if there are concerns, for example, it should be up to the health care team, the perioperative team, to refer to a social worker or [provide] any care [that] patients might need. 

Then there are simple things, like visual aids or hearing aids. I remember several years ago, [you were told], “If you have glasses and hearing aids, just leave them at home, you’re going to lose them in the hospital.” Now we know that is not the correct way. It is very important for these patients after surgery—so that they know where they are, they understand what's happening around them—to have all of these aids available to them immediately…Patients after surgery, when they go to the recovery unit, those should be made available, and that seems to have a huge impact in decreasing, for example, delirium. 

Another very important point that I also wanted to discuss is the adopting healthy lifestyles, [which is] just one recommendation [from] the World Health Organization. Physical activity, cessation of tobacco, making sure that your blood pressure and your diabetes are well controlled—they have a huge impact. And this is what we’re discussing; the care has to start before surgery. If you have time to optimize your patient, your outcomes will be better—they will be better also for the patients and their families.

What are the key takeaways for clinicians and those in the field of neurology? What can they do to address this concern?

I think we need to start telling our patients that the advances in surgery anesthesia, they can improve their function and quality of life, especially in the older patients—because if they need a hip replacement and they can walk they cannot have a healthy lifestyle. So, identifying the risk factors that can be optimized preoperatively is key at this moment. While we are still trying to untangle all the mechanisms that are behind these diseases, identifying patients that are at high risk for developing these conditions, they should trigger immediate evaluation and optimization.

Transcript edited for clarity.

REFERENCE

Vacas S, Cole DJ, Cannesson M. Cognitive decline associated with anesthesia and surgery in older patients. JAMA. 2021;326(9):863-864. doi:10.1001/jama.2021.4773