Pulmonary and Critical Care Physician and Geriatrician Dr. Adrian Austin and Division of Geriatric Medicine Chief Dr. Jan Busby-Whitehead’s study on pre-operative cognitive impairment, post-operative delirium, and longterm cognitive function after nonemergent surgery is the lead article in a recently published issue of JAMA Surgery.
Among the study’s key findings are that patients with pre-operative cognitive impairment actually improve after surgery and that post-operative delirium contributes to 30-day and 90-day cognitive decline among all adults, not just the oldest patients.
Delirium is a sudden change in mental status that can last days or weeks, complicate recovery, and be enormously stressful for both patients and families. Patients and families should be prepared for the possibility of delirium, which can be frightening for family members without context for what is happening and why their loved one’s mental state is suddenly so altered. Delirium can bring on agitation, confusion, anger, fear, and a range of unpredictable behaviors.
Pre-operative Cognitive Impairment and Surgery
Pre-operative cognitive impairment improving after surgery “seems counter-intuitive, but if you think about it, it makes sense,” says the study’s lead author, Adrian Austin, MD, MCSR.
Patients have surgery for a reason, which could be impacting their thinking, memory, and focus. Alleviating this issue, says Austin, can lead to an improvement in cognitive ability. “Pre-operative cognitive impairment alone should not preclude patients from having the indicated surgery,” says Austin, “which may actually improve cognitive function.”
Post-operative Delirium and Cognitive Decline
The study’s second major finding was, in fact, not surprising: patients who experience delirium after surgery show 30-day and 90-day cognitive decline. “We need to be cognizant of this and realize that delirium impacts everybody,” says Austin, “not just older patients.”
Dr. Busby-Whitehead emphasizes the importance of post-operative measures that can help to minimize delirium such as mobilizing early and ambulating frequently, maintaining good sleep / wake cycles, and keeping cognition aids like glasses and hearing aids with the patient.
Patients Undergoing Surgery Should Be Advised on Potential Delirium
Patients and family members benefit when they know what to expect and how best to support their loved ones. Austin and Busby-Whitehead stressed the importance of surgeons preparing patients for the possibility of delirium.
“Delirium is one of the more common complications after surgery, at least in older adults,” says Busby-Whitehead. “Delirium occurs after 15% of elective noncardiac surgeries and in up to 50% of more high-risk procedures, so it’s wise to let families and patients know there’s a chance that they’ll have delirium after surgery, and that the surgeon and hospital will try to minimize contributing factors.”
For surgeons and hospitals, a focus on minimizing delirium aligns well with early recovery protocols that focus on getting people up and moving and keeping a good post-operative day / night cycle. “These can seem like trivial issues,” says Austin. “But they can affect our outcomes, and if we’re not thinking about them, we’re less likely to implement them.”