Preoperative Neurocognitive Evaluation

Prior to surgery, people typically undergo a preoperative medical evaluation to assess for risk factors for complications related to the surgery and anesthesia, and guidance as to how to manage and reduce those risks.

An important complication related to surgery and anesthesia is postoperative delirium. Postoperative delirium is a transient state of abnormal attention and awareness that occurs after surgery and anesthesia, usually in postoperative days one through three. The symptoms fluctuate and tend to also include confusion and disorientation. Sometimes a person may hallucinate, become agitated, or have altered sleeping patterns with sleeping during the day and being awake all night.

Postoperative delirium is associated with increased length of hospital stay, increased hospital readmission rate within thirty days, increased likelihood of discharge to a facility, increased functional decline, and increased mortality.

Postoperative delirium is a risk factor for postoperative cognitive dysfunction, which is also associated with increased mortality.

Risk factors for postoperative delirium include older age, baseline cognitive impairment, functional impairment, a prior history of delirium, certain medications used for mood, sleep, or pain, a history of alcohol abuse, anemia, depression, living in a facility, and having multiple comorbid illnesses.

Most of the risk factors for postoperative delirium and postoperative cognitive dysfunction are known prior to surgery, but unfortunately some people may have cognitive impairment and not realize it, or maybe their loved ones noticed something mild but assumed it was just normal aging rather than an early stage of dementia.

Screening all older people for memory impairment prior to surgery would be one strategy to ensure that the increased risk for postoperative delirium and postoperative cognitive dysfunction was known, so that the person and their family had proper informed consent and anticipatory guidance.  This practice has been recommended by the American Geriatric Society, the American College of Surgeons, and the American Society of Anesthesiologists, however it still remains underutilized. A comprehensive behavioral neurology evaluation prior to surgery includes screening for memory impairment, addressing strategies to reduce risk factors for postoperative delirium, and personalized counseling to optimize brain health before and after surgery.

References and Resources

  1. https://www.asahq.org/brainhealthinitiative/toolsforpatients
  2. Chow, WB, Rosenthal, RA, Merkow, RP, Ko, CY, Esnaola, NF, American College of Surgeons National Surgical Quality Improvement, P, & American Geriatrics, S. (2012). Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg, 215(4), 453-466. doi:10.1016/j.jamcollsurg.2012.06.017
  3. Berger, M, Schenning, KJ, Brown, CHt, Deiner, SG, Whittington, RA, Eckenhoff, RG, Angst, MS, Avramescu, S, Bekker, A, Brzezinski, M, Crosby, G, Culley, DJ, Eckenhoff, M, Eriksson, LI, Evered, L, Ibinson, J, Kline, RP, Kofke, A, Ma, D, Mathew, JP, Maze, M, Orser, BA, Price, CC, Scott, DA, Silbert, B, Su, D, Terrando, N, Wang, DS, Wei, H, Xie, Z, Zuo, Z, & Perioperative Neurotoxicity Working, G. (2018). Best Practices for Postoperative Brain Health: Recommendations From the Fifth International Perioperative Neurotoxicity Working Group. Anesth Analg, 127(6), 1406-1413. doi:10.1213/ANE.0000000000003841
  4. Mahanna-Gabrielli, E, Schenning, KJ, Eriksson, LI, Browndyke, JN, Wright, CB, Culley, DJ, Evered, L, Scott, DA, Wang, NY, Brown, CHt, Oh, E, Purdon, P, Inouye, S, Berger, M, Whittington, RA, Price, CC, & Deiner, S. (2019). State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. Br J Anaesth, 123(4), 464-478. doi:10.1016/j.bja.2019.07.004

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