ER physician’s opinion: How to think about anesthesia and dementia.

I often hear caregivers saying their persons’ dementia worsened after anesthesia.

It is a common topic discussed inside support groups.

Just like in text messages, online posts can leave a lot out.

I have found myself wondering if the caregiver holds the belief that it was the anesthesia alone that made their person’s dementia worse.

This is not a post meant to downplay the risks of anesthesia to a person living with dementia.

There is a known risk of worsening brain function (cognitive impairment), after anesthesia.

The risk is greater for those who are living with dementia.

Anesthesia can absolutely contribute to worsening dementia symptoms.

The reasons and theories as to why are many and it is a challenging topic to study.

My goal for this post is to help you consider the many causes for worsening dementia symptoms after anesthesia.

My experience as a physician tells me we should be considering things a bit more broadly when it comes to this topic.

Do not use what I say here to determine if your person should have or not have a surgery.

Any potentially life altering decision like this needs to consider the person as an individual and involve a discussion between the decision maker and the medical care team.

The decision to have a surgery requires a weighing of the risk and the benefits for the individual person.

I do want to discuss some of what goes into weighing risk with you here.

But first, let’s think about the “big picture.”

Why is anesthesia used?

When a surgeon is operating on someone no one wants them to feel pain.

It is important they are not anxious, breathing fast, accelerating their heart rate and blood pressure.

For major operations we do not want to be conscious while another person is cutting into us.

A patient moving around, not relaxed enough or not paralyzed, is going to make the job of the surgeon much more difficult and the risk to the patient much higher.

There are medication classes to treat each of these situations everyone wants to avoid and they are often used in combination.

Why is anesthesia risky to the whole body and not just the brain?

When the medications used in anesthesia are given, the person’s blood pressure, heart rate, the rhythm of their heart, and their oxygen level can all be easily affected. (Temperature is also closely monitored.)

These are a person’s “vital signs.”

The deeper the anesthesia, general anesthesia being the “deepest,” the more risk there is to causing changes in vital signs.

General anesthesia is when a person is “put under.” They are unconscious, heavily sedated, and often paralyzed. Here’s an article to read more about general anesthesia.

If paralayzed the person will not be able to breathe on their own. They require support so their body can continue to exchange oxygen for carbon dioxide.

Anesthesiologists and their teams are experts who monitor the patient and provide all of this support. They know what to do when the person’s vital signs change in a way that requires action or correction.

Abnormal vital signs for too long can cause a person physical harm.

For example, if someone’s blood pressure is too low they are not going to get as good of blood flow to their organs. Organs like the heart, kidney, and brain are very sensitive to low blood pressure.

Your blood is how your organs receive oxygen.

Having low blood pressure or low oxygen levels for too long can cause injury to the organs.

Controlling someone’s airway, their breathing and thus their oxygen levels can be challenging for a lot of reasons.

It is often challenging when patients are overweight and very sick or elderly.

I could write a post entirely dedicated to complications that come up just when trying to intubate someone and regulate their breathing because I do this emergently in the ER.

The anesthesiology team faces the same issues we have in the ER, but they have to control all of this while someone is having an operation.

There is always a risk associated with anesthesia, but I want you to consider something for a moment…

Think about it.

Why does the person need anesthesia in the first place?

There would be no need for anesthesia without a need for surgery.

Let’s go back to the big picture.

Why do surgeons operate?

Broadly speaking, they are trying to treat or prevent a disease or injury from worsening.

There is something underlying happening to the person’s body.

Surgeons cause physical trauma to the body which results in additional stress to the person through the need for recovery.

Leaving anesthesia completely out of it, surgeries have their own risks.

There is always a risk of something going wrong with the procedure itself or during recovery.

Here’s an example.

Say someone living with dementia falls. They fracture one of their hips and have surgery to repair it.

If there are no issues with the anesthesia and the surgery goes smoothly, they still have a chance of developing infection in the surgical wound or in the hip joint itself.

They have a risk of developing a blood clot in their leg (DVT-deep vein thrombosis) which could travel to their lung (pulmonary embolism).

Falling with another injury is now more likely.

There’s the risk of constipation, a bedsore, or a urinary tract infection from needing a catheter.

I could go on. Managing complications is what I do at work.

Even if the time in the operating room went exactly as planned, all of these known complications of hip surgery are possible.

They are more likely for the person living with dementia.

Any of these complications make the risk of worsening dementia symptoms higher.

What can make a person at higher risk of a bad outcome from surgery?

I don’t think you really need me to tell you this. You likely know it instinctively.

The more difficult and invasive the surgery, the higher the risk.

“Major” surgeries on the brain, those which require opening of the chest, heart surgeries, complicated abdominal surgeries, or those on a large joint (hip, knee) are more risky to name a few.

The longer the operation and the more challenging it is for the surgeon translates into higher risk.

Complicated and “major” surgeries mean a higher chance of the recovery process not going smoothly.

You also know how healthy a person is on a day to day can affect their risk of surviving surgery and in having issues recovering.

I’m sure you know someone who was told they could not have surgery because the risk was too high for them. This was likely in large part due to their underlying health issues.

A person’s age is often a contributing factor when surgery is not an option.

What increases the risk of a complication from anesthesia?

The risks are pretty much the same as those of a surgery not going well.

Here’s a list of the major contributors:

A more complicated surgery (more challenging to complete for the surgeon, unexpected issues that popped up during the surgery prolonging their time under anesthesia)
A “major” surgery
Underlying poor health (heart and lung disease especially)
Obesity
Advanced age
Someone who is critically ill needing surgery
An emergent need for surgery

I want to speak a bit about emergency surgeries compared to elective surgeries.

What are elective surgeries?

Elective surgeries are planned. They are scheduled. You know they are going to happen.

The person is usually “medically cleared.”

The intention of having someone “medically cleared” is to attempt to uncover, and when possible, to intervene and decrease risk. This can involve more tests or visits with doctors prior to surgery.

The team wants to do what they can to get the person’s risk as low as possible prior to surgery.

However, the risks do not go away.

To be clear, if someone is having elective surgery on their heart, brain, or any other major surgery they still have a risk of having complications from surgery and anesthesia.

I am not saying elective surgeries are fine, totally benign, and you should go for them.

The benefit of elective surgeries is time. There is more time to think and strategize how to decrease risk.

There could be a different method or approach a surgeon could use or a different type of anesthesia planned.

A decision to perform surgery on someone living with dementia is a big deal.

When presented with the possibility of having elective surgery, it allows time to think things through and truly weigh out the risks and the benefits to the person.

Emergent surgeries are those that are unplanned.

The risk of not doing the surgery is typically higher than the risks of the surgery itself and what could potentially come after.

High risk of severe infection, bleeding, and death is often what forces the team’s hand to perform an emergent surgery.

Here are a few examples of emergent surgeries;

repair of hip fractures
treating bleeding in the brain
removing a ruptured appendix
repairing a hole in the bowel (aka, a perforation)

With an emergency surgery there is usually no or little time for a thorough medical clearance. The team will quickly weigh the risks and benefits. There may be limited time to discuss the options with you.

Because there is not the chance to optimize the person’s health prior, recovering from these surgeries can often be more challenging.

I want to pause here and remind you that medicine is designed to do things to people.

We act to keep people alive and we often do so quickly. If you are not prepared to make choices like this you could agree to have a surgery for your person that in hindsight they would not have chosen.

The need for many emergency surgeries are foreseeable and are something you can plan for.

I teach this my course along with a framework for how to think through big decisions like this in real time.

Learn at your own pace with steps to follow.

You can stop carrying around the stress from not knowing what is normal and likely to happen and what medical decisions you might have to make.

If you would like a process for creating a treatment plan that you can fall back on at any time when asked to make your person’s medical decisions, I invite you to let me show you how inside my course.

You can sign up here. Send me an email at brittanylambmd@blambmd.com with any questions.

When surgeries are done emergently, the risk of complications from anesthesia and surgery are higher.

There are many reasons for this.

Oftentimes these surgeries take longer, they are more challenging for the surgeon and anesthesia team with issues popping up that were unexpected.

People are often not well when they go into surgery. Their bodies are under stress when they enter the operating room.

Emergent surgeries often go along with longer recovery times.

Longer recoveries and higher stress on the body increase someone’s risk of more days in the hospital and complications coming up during recovery.

For the person living with dementia, all surgeries, but especially those done emergently, carry a risk of worsening cognitive functioning. Why?

Even when the surgery and anesthesia go smoothly, there is still a risk of worsening cognitive functioning.

One theory is that there is a “whole body” (systemic) inflammatory response due to the surgery.

This causes more sensitivity to and worsening inflammation in the brain which leads to further damage to the brain tissue.

Delirium could be contributed to by this mechanism.

It is known that a diagnosis of dementia, or any level of cognitive impairment, even mild (MCI), before surgery and anesthesia, means a person’s risk of delirium after surgery is higher.

Without any obvious issues due to surgery or anesthesia we still see patients who become delirious.

When surgery or anesthesia don’t go as planned and complications come up, the risk of delirium in the person living with dementia is even higher.

What is delirium?

It is a sudden change. It is not dementia or cognitive impairment and is often reversible.

What it looks like will be different for each person.

Delirium brings an abrupt change from the person’s baseline functioning and the way they typically behave and engage with the world.

We commonly see worsening confusion, changes in behavior, altered levels of awareness, and overall worsening thinking and attention. People are much more disoriented.

Agitation is common and can be alarming to witness and challenging to treat.

Agitation is obvious to caregivers and medical staff, but the person could also appear slow and withdrawn.

People can go back and forth between these high and low states of delirium.

It is very common in those living with dementia when they are unwell, especially when there is a need for them to stay in the hospital.

There is always a risk of delirium in the hospital even when there is no surgery or anesthesia.

Remember, for those living with dementia, delirium is also much more likely after a surgery. Even if the surgery and anesthesia went smoothly with no issues.

The longer a person is in the hospital recovering from a surgery, the more likely they are to become delirious.

Delirium can cause worsening dementia symptoms long term.

The longer someone is delirious the more likely they are to have a permanent change in their cognitive abilities. Their risk of death is also higher.

So what can you do as your person’s advocate or decision maker?

Your first responsibility is always knowing your person’s goals of care (GOC).

There are times in which a surgery may not line up with your person’s goals.

If you don’t openly communicate their overall goal, the team may never ask you whether the surgery is something your person would want.

Remember healthcare is set up to do things to people. There are usually good intentions behind this.

However, the default to continue to prolong someone’s life, will not always follow the values, wishes, or preferences of someone living with dementia.

It is your job to protect your person. Advocate for them.

Identify and make their goals known so the treatments they receive, including any surgeries, are in their best interest.

When choosing whether or not your person is going to have a surgery, elective or emergent, tell their team you want to weigh the risks and the benefits and consider what could happen after the surgery.

Understand that anytime your person has a surgery they are at risk of worsening dementia symptoms and an overall decline.

Each surgery will have its own level of risk.

In general, procedures like colonoscopies, cataract surgeries, and other surgeries where the person can go home the same day, carry less risk.

When someone has to stay in the hospital or the surgery is necessary emergently, the risk will be higher.

I hope this post has given you some things to think about. I want you to remember the following two things...

1 – The risk of worsening decline is not due to anesthesia alone.

It is also because of what is happening to the person’s body. Their need for surgery, diagnosis of disease causing dementia, other medical issues, age, and ability to heal can all contribute.

2 – Preventing, recognizing, and treating delirium is extremely important.

What are some questions you can ask (and things you should consider) when your person is being presented with the option for a surgery?

Remember this is not an exhaustive list and can not be used to determine your person’s decision.

It is to be used as a tool to help you have a better conversation with their care team.

You can ask the surgeon:

Is this procedure necessary to sustain life? – Meaning, will they die without it?
What are the benefits of doing this?
Is the purpose of this to prolong their life or to improve or protect quality of life?
What are the alternatives to surgery, if any? What will happen if we don’t do it?
What are the risks of the surgery itself? What things could go wrong during the surgery?
What about my person’s medical issues would make this more risky?
Tell me about the most common complications after surgery. What issues do you think my person is likely to face afterwards?
What does the recovery process look like?
Will they have to go to rehab? Can you help me understand how it might affect their day to day care needs?
Have you seen people do well with my person’s level of functioning and stage of dementia? (You will need to tell them what your person can do for themselves and how they function at their baseline. Have this written down so you can say it quickly.)

Things to consider for yourself:

Has your person had issues with anesthesia or surgery in the past? Everyone on the team needs to know this so anything can be done to try and prevent an issue if you choose to go forward with a surgery.
Make sure they understand your person has dementia. The surgeon needs to know how they function on a day to day so they can help you think through what happens after the surgery and whether or not it will truly benefit them. The anesthesia team needs to know so they can choose the safest plan for anesthesia.
If your person values quality of life over length of life make this well known.
If your person has a DNR (Do-Not-Resuscitate) order make sure you know and ask how the team would handle a situation if your person were to lose their pulse and start the dying process in the operating room.
Make sure the team is aware if your person drinks alcohol regularly as it can affect the choices of drugs used with anesthesia and after surgery. Withdrawal from alcohol can be life threatening and potentially deadly. It will increase the risk of delirium.
If your person has had reactions to sedatives or medications used to treat agitation or anxiety in the past the team needs to know this.
Please be aware that poorly controlled pain can cause delirium, but so can large doses of pain medications. Constipation is also common with pain meds and can cause delirium.
There is a risk of worsening delirium with medications in the benzodiazepine class and with benadryl.
Ask who will be managing your person after the surgery especially if they will be staying in the hospital. You’ll want to know how the hospital monitors for and tries to decrease the risk of delirium. Ask about the plan for pain control.

Questions to ask the anesthesia team:

What is your plan for the anesthesia?
Can you explain to me what you recommend as the best option for anesthesia and the pros and cons of the other options so I can understand your choice?
Specifically ask if there is another option other than general anesthesia (like spinal or regional)?
How will my person be monitored during the procedure? I know you will closely monitor their blood pressure, but I want to make sure we do everything we can to avoid low blood pressure as I know it can cause brain injury.
Can we use the lowest doses of medications possible? I want to decrease the risk of delirium.

I hope this has been helpful for you.

If it has, please share this post with those you know who are caring or advocating for someone living with dementia.

Until next time, all my best,

Brittany Lamb, MD

References:

Mahanna-Gabrielli E. Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies. In: UpToDate, Holt N (Ed), UpToDate, 2022, Waltham, MA. (Accessed on 10/10/2022). Perioperative neurocognitive disorders in adults: Risk factors and mitigation strategies – UpToDate

Falk S. Overview of Anesthesia. In: UpToDate, Jones S (Ed), UpToDate, 2022, Waltham, MA (Accessed on 10/10/2022). Overview of anesthesia – UpToDate