Surgery can cause cognitive losses in some seniors By Judith Graham

Two years ago, Daniel Cole’s 85-year-old father had heart bypass surgery. He hasn’t been quite the same since.

“He forgets things and will ask you the same thing several times,” said Cole, a professor of clinical anesthesiology at UCLA and a past president of the American Society of Anesthesiologists.

“He never got back to his cognitive baseline,” Cole continued, noting that his father was sharp as a tack before the operation. “He’s more like 80 percent.”

His father probably has post­operative cognitive dysfunction (POCD) — a little-known condition that affects a substantial number of older adults after surgery, Cole said.
Some patients with POCD experience memory problems; others have difficulty multitasking, learning new things, following multistep procedures or setting priorities.

“There is no single presentation for POCD. Different patients are affected in different ways,” said Miles Berger, a POCD specialist and assistant professor of anesthesiology at Duke University School of Medicine.

Unlike delirium — an acute, sudden-onset disorder that affects consciousness and attention — POCD can involve subtle, difficult-to-recognize symptoms that develop days to weeks after surgery.
Most of the time, POCD is transient and patients get better in several months. But sometimes — how often hasn’t been determined — this condition lasts up to a year or longer.
Roderic Eckenhoff, vice chair for research and a professor of anesthesiology at the Perelman School of Medicine at the University of Pennsylvania, told of an email he received recently from a 69-year-old man who had read about his research.

“This guy — a very articulate man — said he was the intellectual equal of his wife before a surgery 10 years ago, a significant operation involving general anesthesia. Since then, he’s had difficulty with cognitively demanding tasks at work, such as detailed question-and-answer sessions with his colleagues,” Eckenhoff said. “He noticed these changes immediately after the surgery and claims he did not get better.”

There are many unanswered questions about POCD. How should it best be measured? Is it truly a stand-alone condition or part of a continuum of brain disorders after surgery? Can it be prevented or treated? Can it be distinguished in the long term from the deterioration in cognitive function that can accompany illness and advanced aging?

Some clarity should come in June, when a major paper outlining standard definitions for POCD is set to be published and when scientists will meet at a two-day POCD summit, according to Eckenhoff.

​Here’s what scientists know about POCD:

Background. POCD was first studied systematically about 20 years ago. But reports of patients who appeared cognitively compromised after having surgery date back about 100 years, Eckenhoff said.
An influential 1955 report in the Lancet noted common complaints by family or friends after someone dear to them had surgery: “He’s become so forgetful. . . . She’s lost all interest in the family. . . . He can’t concentrate on anything. He’s just not the same person since.”

How to recognize the condition. There is no short, simple test for POCD. Typically, a series of neuropsychological tests are administered before and after surgery — a time-consuming process. Often, tests are given one week and again three months after surgery. But the tests and time frames differ in various studies. Studies also define POCD differently, using varying criteria to assess the kind and extent of cognitive impairment that patients experience.

How common is it? The first international study of older adults with POCD in 1999 suggested that 25.8 percent of patients had this condition one week after a major non-cardiac surgery, such as a hip replacement, while 9.9 percent had it three months after surgery.
Two years later, a study by researchers at Duke University Medical Center found that 53 percent of adults who had heart-bypass surgery showed significant evidence of cognitive decline when they were discharged from the hospital; 36 percent were affected at six weeks; 24 percent, at six months; and 42 percent, five years after their operations.
Another Duke study of older adults who had knee and hip replacements found that 59 percent had cognitive dysfunction immediately after surgery; 34 percent, at three months; and 42 percent, at two years.

Other studies have produced different estimates. A project examining adults 55 and older who have major non-cardiac surgeries is finding that “upwards of 30 percent of patients are testing significantly worse than their baseline 3 months later,” according to its lead researcher, Stacie Deiner of the Icahn School of Medicine at Mount Sinai in New York City.

Vulnerabilities. The risk of experiencing POCD after surgery is enhanced in those who are older, have low levels of education or have cognitive concerns that predate surgery. Adults age 60 and older are twice as likely as are younger adults to develop POCD.

“People who are older, with some unrecognized brain pathology, or people who have some trajectory of cognitive decline at baseline, those are the patients who you’re going to see some change in one, two or three years out,” said Charles Hugh Brown IV, assistant professor of anesthesiology and critical-care medicine at Johns Hopkins Medicine.
Researchers have examined whether the type of anesthetic used during surgery or the depth of anesthesia — the degree to which a patient is put under — affects the risk of developing POCD. So far, results have been inconclusive. Also under investigation are techniques to optimize blood flow to the brain during surgery.

Mechanisms at work. What’s responsible for POCD — the drugs administered during anesthesia or the surgery itself? Currently, the evidence implicates the stress of surgery rather than the anesthesia.

“Most surgery causes peripheral inflammation,” Eckenhoff explained. “In young people, the brain remains largely isolated from that inflammation, but with older people, our blood-brain barrier becomes kind of leaky. That contributes to neuroinflammation, which activates a whole cascade of events in the brain that can accelerate the ongoing aging process.”
At Mount Sinai, Deiner has been administering two-hour-long general anesthesia to healthy seniors who receive cognitive tests and brain scans before and after. Early results show “very good and rapid cognitive recovery in older adults after anesthesia,” Deiner said. The implication is that “the surgery or the medical conditions surrounding surgery” are responsible for subsequent cognitive dysfunction, she noted.

Advice. Many patients are not told of the risk of POCD during the process of informed consent. That should change, several experts advise.

“Beyond question, patients should be informed that the ‘safety step’ of not undergoing surgery is theirs to choose,” wrote Kirk Hogan, a professor of anesthesiology at the University of Wisconsin at Madison School of Medicine and Public Health, in an article published this year. “Each patient must determine if the proposed benefits of a procedure outweigh the foreseeable and material risks of cognitive decline after surgery.”

“Surgery is a good thing — it improves quality of life — and most older patients do really well,” said Brown of Hopkins. “Our trick is to understand who we really need to identify as high-risk and what we can do about modifiable factors.

“If you’re older and suspect you have cognitive issues, it’s important to let your family physician as well as your surgeon and anesthesiologist know that you’re concerned about this and you don’t want to get worse. That should open up a conversation about the goals of surgery, alternatives to surgery and what can be done to optimize your condition before surgery, if that’s what you want to pursue.”

“We want people to know this does happen but not be too concerned because, typically, it does go away,” said Eckenhoff. “That said, don’t try to make cognitively demanding decisions in the first 30 days after an operation. And make sure your caregivers are prepared to help with anything from paying bills and balancing the checkbook to ensuring that you’re caring for yourself adequately and communicating well with your doctor.”

​This column was produced by Kaiser Health News. KHN’s coverage of these topics is supported by the Laura and John Arnold Foundation and Gordon and Betty Moore Foundation.

WASHINGTON (AP) — Most young adults haven’t given much thought to their own needs as they get older, but a significant number are already providing long-term care for older loved ones, according to a new poll by the Associated Press-NORC Center for Public Affairs Research.
And while those who have caregiving experience put in fewer hours than their older counterparts, they’re more likely to feel stressed out by the experience.
According to the poll, a third of American adults under age 40 have already provided care for an older relative or friend, and another third expect to be called upon to do so within the next five years.

YOUNG CAREGIVERS
According to the survey, 17 percent of young adults are currently providing long-term care to an older loved one, and another 19 percent have done so in the past.
Three-quarters of younger caregivers spend less than 10 hours a week providing care, compared to most caregivers over age 40 who provide at least 10 hours of unpaid care a week. But despite putting in fewer hours of unpaid work, younger caregivers are more likely than older caregivers to say their care responsibilities are at least moderately stressful, 80 percent to 67 percent.
At the same time, most caregivers — younger and older — say they’re getting most or all of the support they need, with young caregivers especially likely to say they receive that support from family members. Younger caregivers are also more likely than older ones to rely at least in part on social media for the support they need, 45 percent to 25 percent.
FEELING UNPREPARED
In addition to the 35 percent who already have experience providing care, another 34 percent of adults under 40 expect to become caregivers at some point in the next five years.
Younger prospective caregivers are more likely than those age 40 and older to say they feel unprepared to take on that role, 53 percent to 37 percent. Still, most say they expect to share caregiving responsibilities rather than take them on alone.
Among all young adults, less than half say they’ve done any planning for the potential care of an older relative.
LACKING CONFIDENCE IN GOVERNMENT
Most young adults have little confidence that government safety-net programs will be there for them as they get older, and they’re not too sure about their own financial situation, either.
Only 16 percent of younger adults are very confident that they’ll have the financial resources to deal with their own care needs when they get older.

​At the same time, only about 1 in 10 expect Social Security, Medicare or Medicaid to provide at least the same level of benefits when they need them, and majorities say they have little to no confidence in that being the case.
Although about 7 in 10 Americans will need some type of long-term care as they get older, just 22 percent of young adults think it’s very likely that they’ll need those types of services themselves someday. And those under age 40 are more likely than older adults to underestimate the percentage of Americans age 65 and older who will need care, 64 percent to 54 percent.
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The long-term care poll was conducted March 13 to April 5 by NORC, with funding from the SCAN Foundation.
It involved interviews in English and Spanish with 1,945 adults, including 423 adults under 40 and 1,522 adults age 40 and older. Interviews were conducted online or by phone among members of NORC’s probability-based AmeriSpeak panel, which is designed to be representative of the U.S. population.
The margin of error for all adults is plus or minus 3.3 percentage points and the margin of error for adults under 40 is plus or minus 6.7 percentage points.
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Online:
longtermcarepoll.org

On Saturday, May 19th from 9:00am – 4:00pm, Community Human Services’ Family Service Centers will offer free, confidential mental wellness screenings to the community. In an effort to reach individuals across Monterey County, CHS is providing this no cost event to connect people with the support services they need. Bilingual clinicians will facilitate mental wellness screenings to identify if an individual’s symptoms are related to depression, mood or anxiety disorders and connect them with the appropriate services.
The Family Service Centers are located at 433 Salinas St., in Salinas and 1178 Broadway Ave., in Seaside.
The event is open to all and free of charge.
Teen stress and anxiety is a growing epidemic. One-third of adolescent’s report feeling anxiety to a significant degree, according to the National Institute of Mental Health, and 62 percent of college students said in 2016 that they feel “overwhelming anxiety;” up from 50 percent in 2011, based on a survey from the American College Health Association. In addition, anxiety disorders are the most common mental illness in the United States, affecting 40 million adults age 18 and older, according to the National Institute of Mental Health. The vast majority of clinical depression cases can be effectively treated. Screenings are often the first step in getting help. Community Human Services’ Family Service Centers offer affordable & supportive clinical behavioral health services year-round to people of all ages.
For more information call, 831.658.3811 or visit https://chservices.org/free-mental-wellness-screenings/


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For today, there are no doctor’s visits. No long afternoons with nothing to do. No struggles over bathing — or not.

At the National Gallery of Art in Washington, D.C., a group of older adults — some in wheelchairs, some with Alzheimer’s — and their caregivers sit in a semicircle around a haunting portrait of a woman in white.

“Take a deep breath,” said Lorena Bradford, head of accessible programs at the National Gallery, standing before “The Repentant Magdalen” by Georges de La Tour.

“Now, let your eyes wander all over the painting. Take it all in. What do you think is going on?”

“I think she looks sad,” said Marie Fanning, 75, of Alexandria, Va., an Alzheimer’s patient.

“Yes. Yes, she looks sad,” said Bradford.

“This is such a gift,” Bill Fanning, 77, Marie’s husband and caregiver, said of the outing.

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