Anesthesiology Today Annual Meeting Edition
Think a little brain fogginess might be something more? ASA’s Perioperative Brain Health Initiative (PBHI) is leading the charge to equip anesthesiologists with the tools they need to effectively screen and care for patients at risk for pre- and postoperative neurocognitive decline.
Sunday’s session “Perioperative Brain Health Initiative: Update and Implementation Strategies” takes a comprehensive look at this initiative launched by the ASA in 2015. Today, the PBHI and its accompanying website serves to provide a resource for education, treatment, and implementation guidelines, working with ASA Committee on Geriatric Anesthesia and other partners such as AARP. Carol J. Peden, MD, MB, ChB, MPH, of the University of Southern California in Los Angeles, is chair of the initiative and among the session speakers.
“There was a time when the lay community believed postoperative delirium and cognitive decline was tied to anesthesia, but now we know it’s more complicated and is related to neuro-inflammation and a multicomponent stress response to surgery and anesthesia,” Dr. Peden said. “Anesthesiologists screen the respiratory and cardiovascular systems, but we don’t routinely do simple screening of the brain. The brain initiative highlights the tools and the need to improve preoperative screening and potentially reduce postoperative delirium or prepare for it.”
The initiative engages a multidisciplinary group to work with providers, payers, and the public to create a low-barrier access program to minimize the impact of pre-existing cognitive deficits and optimize the cognitive recovery and perioperative experience for adults 65 years and older undergoing surgery.
Perioperative Brain Health Initiative: Update and Implementation Strategies
In most cases, Dr. Peden said, postoperative cognitive decline is temporary and eventually disappears. Yet, by having anesthesiologists add simple brain screening techniques to their preoperative checklist, providers may be able to positively impact postoperative outcomes or share their concerns with patients and families.
To be clear, she said, anesthesiologists are not diagnosing dementia. They are flagging concerns or determining anesthetic sedative and analgesic drug interventions. Some of those interventions might include using dexmedetomidine instead of benzodiazepines and opioids in the ICU for sedation, avoiding benzodiazepines for older patients before anesthesia, not giving diphenhydramine for sedation or sleep, and removing meperidine from order sets.
Postoperative delirium and delayed cognitive recovery primarily affect elderly surgical patients. The incidence of postoperative delirium is variable, and on average ranges from 5% to 15%. However, with certain high-risk groups, such as patients with hip fracture, the range can be between 16% to 62%, she said. Should delayed cognitive recovery occur, the incidence is highest immediately after surgery, with recovery usually happening over a period of months.
Dr. Peden reminds anesthesiologists about the importance of talking with patients and their families about delirium and delayed cognitive recovery by providing checklists covering risk factors and promoting supportive actions such as family support and reassurance, and returning hearing aids and glasses immediately after surgery. Even getting healthy before surgery can help, she said. There is a flyer available for anesthesiologists to share with their patients, created by the brain health campaign and the American Geriatrics Society, which can be downloaded from the PBHI website.
“Getting fitter before surgery just makes good sense. You’re asking your body to handle a lot to undergo surgery,” Dr. Peden said. “You wouldn’t run a marathon without first preparing.”
During the session, the panel will update attendees on related activities between the initiative and other groups such as the American Hospital Association, the Age Friendly Health System Initiative, and consumers through AARP.