May 24, 2010

Addressing Anesthesia Concerns
By Lindsey Getz
For The Record
Vol. 22 No. 10 P. 24

If both healthcare professionals and patients follow the recommended steps, the threat of anesthesia aftereffects in older adults diminishes significantly.

In general, patients and their caregivers can help by providing the anesthesiologist with as much medical history as possible. For example, discuss prior illnesses and hospitalizations, past surgery, and current treatments.

Anesthesia today is generally very safe. However, there are some risks for anyone undergoing surgery that requires the use of anesthesia, and the occurrence of complications tends to be higher for the aging population. Most anesthetic risk to older patients is related to existing medical conditions rather than age, but it’s still crucial to give this age group specialized attention when it comes to anesthesia use. To ensure patients have the best and safest possible experience, it’s important to be educated on the facts.

The two most prominent complications are also the most feared by elders undergoing anesthesia: postoperative delirium and postoperative cognitive dysfunction (POCD). Delirium is the most common complication and may occur in as many as 40% (or more) of older patients following surgery, especially major and emergency surgeries, or in patients with significant medical problems. These patients can be confused and disoriented for several weeks after surgery, which can lead to prolonged hospitalizations and is sometimes associated with a worse overall prognosis.

By contrast, POCD is a more subtle process, and family members may not recognize that the problem exists. True POCD is identified through neuropsychological testing. Anesthesia’s role in the development of POCD is unclear, making it the topic of expanded research in the anesthesiology field. “Overall, the anesthetic risks in the older population will be very much related to how healthy that person is,” says Sheila R. Barnett, MD, chair of the American Society of Anesthesiologists’ Committee on Geriatric Anesthesia. “The highest-risk older patients are those with significant cardiac disease, especially congestive heart failure, and patients with very impaired functional capacity due to heart and lung disease. In addition, preexisting neurological conditions like Alzheimer’s, prior significant cerebrovascular events or strokes, and Parkinson’s disease greatly increase the risk of postoperative delirium.”

Avoiding Complications
In terms of anesthesia’s postoperative effects, neurological changes tend to be the ones patients and their families worry about the most. Barnett says common questions raised are “Will I be confused afterward?” “Will I become forgetful or suffer memory loss?” and “Will I be unable to do everything I did before?” It’s important that these questions be addressed to help put fears to rest. But it’s also important that patients and their caregivers do what they can to help avoid these complications.

Though it seems obvious, if a patient has experienced trouble with anesthesia in the past, then it’s important to mention this fact prior to undergoing anesthesia again. “Most anesthesiologists will automatically ask that, but if they don’t, it’s one of those important points to bring up so that the same problems don’t happen again,” says Barnett. “If you were confused after anesthesia in the past or become easily confused by changes in environment, you may be more vulnerable to that happening after surgery. In these instances, the anesthesiologist may be able to help by avoiding certain medications such as meperidine and long-acting benzodiazepines or by offering a type of anesthesia such as a nerve block that may result in a reduction in the need for systemic analgesics and sedatives.”

In general, patients and their caregivers can help by providing the anesthesiologist with as much medical history as possible. For example, discuss prior illnesses and hospitalizations, past surgeries, and current treatments. For patients of all ages, the period leading up to surgery is a great time to focus on being as healthy as possible. “This is a prime opportunity for patients to see their primary care physician and get checked, ensuring that the patient is as ‘tuned up’ as can be,” says Barnett. “The healthier you are prior to undergoing anesthesia and surgery, the more likely you’ll have a smooth recovery.”

Similarly, though often overlooked, depression is common in elders and has been associated with cognitive difficulties following surgery. It’s important that patients are treated for depression prior to undergoing surgery, according to Barnett.

Informing the doctor of all current medications, including over-the-counter ones, is also critical in preventing complications. “Patients need to be honest and thorough regarding any medications they are taking,” says Barnett. “Medication regimes can be complex in older patients with multiple illnesses and in these instances, family members or caregivers can help assemble lists of medication that include doses and frequency. This is a great help to the anesthesiologist.”

Barnett adds that those involved with older adults’ care can often be supportive not only in knowing exactly what medications their patients are taking but also by helping patients know what they can and can’t take prior to surgery. “There can be a lot of confusion about what medications are OK to take before surgery,” she says. “In general, the surgeon will provide a list of what not to take. However, there are many medications such as high blood pressure and heart pills that are important to continue taking prior to surgery. Many people just assume they should stop all medications or don’t take them the day of their surgery. This can result in patients arriving for surgery with very high blood pressure and poorly controlled pain.”

In addition to being up front about medication usage, Barnett says family members and caregivers also need to be honest about exactly how well the patient functions at home on a daily basis. Functional status is one of the most important predictors of outcome after anesthesia. Sometimes, especially in the presence of early dementia or depression, an elder may claim to be fully functional, but caregivers know otherwise. “If a patient isn’t functioning well at home, they will be at higher risk of a prolonged recovery and may have more struggles, especially with confusion and delirium,” says Barnett. “It’s important to be honest about how independently the patient is functioning prior to surgery, otherwise the surgery and anesthesia may ‘unmask’ significant limitations and lead to a stormy and prolonged recovery period.”

Specific Requests
While on-staff anesthesiologists at hospitals often work with patients of any age group, many elders prefer to see a geriatric specialist. This can be especially beneficial for patients who are taking multiple medications or have a more complicated medical history. A geriatric anesthesiologist specializes in treating older adults and has specific experience caring for patients of this age group both preoperatively and postoperatively.

Another request that some older adults make is the use of a brain monitor. Barry Friedberg, MD, a board-certified anesthesiologist, developer of propofol ketamine anesthesia for cosmetic surgery, and president and founder of the Goldilocks Anesthesia Foundation, a nonprofit organization with a mission to educate Americans about the risks of anesthesia overmedication, advocates that any patient undergoing anesthesia be hooked up to a brain monitor, which can help avoid the receipt of too much anesthesia and the possibility of postoperative dementia by allowing the doctor to know exactly how much of the drug is needed. “If you don’t use a brain monitor, the person administering the anesthesia may give you more than you need for fear of giving you too little,” he says. “I believe patients should insist on a brain monitor when they undergo anesthesia.”

Friedberg says closely monitoring the amount of anesthesia administered, especially in older adults, can impact how much extra care the patient will need following surgery. “A patient who has been given too much anesthesia is going to be foggy and require extra care,” he says. “This can be avoided. Through my nonprofit, it’s been my mission to educate the public. If a patient meets with their physician and finds out the hospital does not use brain monitors, then they should go somewhere else.”

After the Surgery
One role in which professionals caring for elders can perhaps have the biggest impact is in the postoperative phase. Clinicians can be helpful in making the recovery period easier on their patients. They can keep patients comfortable by ensuring their eyeglasses, hearing aids, and any other necessary devices are available to them as soon as possible following surgery. When the patient returns home, it’s an important time for caregivers to stick to established and familiar routines that will help the patient reorient himself or herself to the home environment. “The time following a procedure can be confusing and overwhelming for a patient, and it is not a good time to suddenly change things,” says Barnett. “Patients need to become reoriented with their routine.”

Of course the recovery process is also dependent on how well patients understand and follow doctors’ orders. Patients or their caregivers should ask for written instructions that include when medications should be resumed, what types of activities are advisable, how much pain to expect, and how often pain medications can be taken. It is important to help older patients identify when and why they should contact their surgeon or anesthesiologist after surgery if there appears to be a problem. Older patients have a diminished sense of thirst and are at risk of developing dehydration that can lead to confusion and falls in frail elders. Following surgery, caregivers can help make sure patients are eating and drinking adequately, says Barnett. “The trend in surgery is to try to get patients home quickly, and usually this is best for the patient. However, this also means that caregivers may need to have extra help around,” she says. “I’m often surprised by how many patients go home and don’t have someone there.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.