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New York Consortium for Alzheimer Research and Education
The New York Consortium for Alzheimer Research and Education (N.Y.C.A.R.E.) is the joint effort of
the Alzheimer’s Association New York City Chapter and the Education and Information Cores of the
Alzheimer’s Centers — Columbia University, College of Physicians and Surgeons; Mount Sinai Medical Center; and New York University School of Medicine funded by the National Institute on Aging.
Cognitive Problems Following Anesthesia
Almost all patients and their family members are
apprehensive when surgery is needed. When
the patient is elderly and has dementia there are
many additional concerns including the post-operative
effect of general anesthesia. We interviewed Dr. Alex
Bekker, Professor of Anesthesiology and Neurosurgery
at NYU School of Medicine, to learn about the impact
of surgery and anesthesia on older adults, highlighting
those with memory impairment.
Interview with Dr. Alex Bekker:
Are there cognitive problems associated with
anesthesia on older adults?
The majority of patients typically come through
surgical and anesthetic experiences quite intact.
However about 10% of people of over age 65 have
some problems postoperatively (i.e. following surgery).
There are two types of problems: 1) delirium, which
is a sudden decline in attention, focus, perception and
thinking, causing a person to appear confused and out
of touch with his or her surroundings; and 2) post
operative cognitive dysfunction (POCD) which includes
problems with memory, attention, concentration and
planning (also known as executive function).
When do these problems occur and how long
do they last?
The onset of delirium is usually within 1 to 3 days
after surgery and may last up to a week. If it lasts
longer, a thorough diagnostic evaluation should be
done to identify any treatable causes. POCD is usually
reported later, often after a patient has left the hospital.
It sometimes isn’t noticeable until the patient attempts
to return to routine activities, which may now seem
more difficult to do. People with POCD often recover
after several months or even a year after surgery.
Is an elderly person with intact memory at risk
for dementia after surgery?
While most people recover, in some cases the
cognitive deficit may persist and may herald the
beginning of serious cognitive decline and dementia.
One theory is that those who have a serious post
operative problem may have had a pre-existing deficit that the surgical experience, including the stress, the
anesthesia and the hospital environment may uncover.
How do surgery and anesthesia affect people
with dementia?
Those with dementia are at an increased risk of
complications following surgery. They may awaken
more slowly and are more likely to experience
confusion and delirium. This might translate into
longer stays in the post surgical recovery room and
longer hospitalizations as well.
What causes these problems?
Many things may contribute to confusion and
cognitive problems postoperatively. Some medications
that are used to avoid symptoms such as nausea
following surgery have an “anti-cholinergic” effect.
This is the opposite of the effect of cholinergic drugs
such as donepezil (Aricept) that are often used to treat
Alzheimer’s disease. Drugs used in surgery for post
operative pain control may also worsen confusion.
What can be done if the patient exhibits
Delirium or Postoperative Cognitive
Dysfunction (POCD)?
It is important for individuals and their families
to report changes in memory and thinking to their
physicians either during the hospital stay or after they
go home, as certain medications may make delirium or
POCD worse. If cognitive changes develop suddenly, the
patient should be taken to the Emergency Department
immediately because conditions such as stroke may be a
consequence of the surgical and anesthetic experience.
What should an older adult scheduled for
surgery discuss with the surgeon or
anesthesiologist?
It is important to report existing memory or cognitive
problems or illnesses such as Alzheimer’s disease. It is
also important to report past problems following surgery
or anesthesia as these problems may recur. Finally it is
important to report all current medications, including
over-the-counter or “herbal/natural” remedies. The
doctor will advise the patient about whether to
continue or stop taking these medications, and will provide information about post operative pain control
medication and risk of side effects, including the
possibility of confusion or cognitive problems.
What types of anesthesia are associated with
more negative outcomes in people with
dementia?
There are no studies which clearly demonstrate
the advantages of a particular type of anesthesia. Some
data suggests that intravenous anesthetics, such as
dexmedetomidine are less damaging to the brain than
inhalational agents. Laboratory studies indicate that
inhalation anesthesia may promote processes that lead
to synthesis of proteins associated with Alzheimer’s
disease but further study is needed. There are some data
which suggest that titration of medications to specific
patient’s need using devices to measure the level of
anesthesia may improve the outcome.
To what degree can a patient be involved in the
choice of anesthesia?
Because some anesthetics are particularly appropriate
for some surgeries and because of the patient’s general
state of health, the anesthesiologist may not be able to
accommodate all patient wishes but it is important to
ask whether there is a choice. Communication between
patient, doctor and family is always key.
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