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Postoperative Cognitive Impairment

“Approximately 12% of apparently previously cognitively well patients undergoing anaesthesia and noncardiac surgery will develop symptoms of cognitivedysfunction after their procedure” (Needham et al., 2017, p. 115)

POCD (postoperative cognitive impairment) is real, and seems to be on the increase. Whilst I have heard about this, it was only once I experienced it firsthand with my mother that I realised what it meant. After hip replacement number four (don’t ask), my mother came home after a week in hospital. The first night at home she walked into the kitchen and started talking incoherently. As is the norm in our household, we at first started laughing and thought it was very funny. The look on my mother’s face quickly brought silence to the room. She was really confused. It took me a few minutes to realise that my mother was delirious. I was shocked, and had no idea what to do. She was clearly upset by her state of delirium, not knowing what she was saying or where she was. We helped her back to bed, sat with her until she fell asleep.

Hospital induced delirium and postoperative cognitive impairment can last for a few days, sometimes for up to six months. This is not dementia, or ‘sudden onset dementia’ as I have heard people call this state of confusion, and can happen to anyone after anaesthetic. Older people are more at risk, and of course people living with prior mild cognitive impairment even more so. Since the incident with my mother I have seen this happen more and more with older people, especially after hip surgery.

Researchers cannot agree on deznitions of the phenomena, nor on interventions to prevent it from happening, making the evidence of prevalence and incidence skewed. Sufzce to say that it is something that one would like to avoid at all costs, especially for older people living with cognitive impairment (dementia). Most hospital employees are not trained to deal with older people living with dementia, far less so when they are in a state of delirium – standard practice often being to physically restrain such patients. This causes increased stress and confusion, making the whole experience even more traumatic for the patient and the family. To sedate a patient whilst in a delirium would only add insult to injury.

So – what to do? In terms of the actual anaesthetic there is little one can do, other than to avoid it! Many doctors are prepared to do hip or knee replacements with an epidural, rather than a general anaesthetic. Keeping the patient and family well informed is a step in the right direction. And oh yes – training hospital staff to deal with patients who might be in a delirium or are cognitively impaired. Physical restraints are never a good idea, as much as they might be unavoidable at times.

Communication, communication, communication is key. If we know what to expect it is often less traumatic than when we are suddenly confronted with strange behaviour or emotional outbursts. A calm environment goes a long way to helping someone deal with delirium and confusion – of course very few intensive care units are calm environments. Keep noise levels down, switch off the television! Do not talk over the patient, even if you think they are sedated and don’t know what is going on. Get to know the patient, their language preferences, their food and drink preferences, etc.

We need to create hospital and step-down facilities that are inclusive, dementia friendly environments. It will not cost more money – in fact it will save millions of rands in preventing adverse clinical outcomes!

Postoperative cognitive dysfunction and dementia: what we need to know and do M. J. Needham, C. E. Webb and D. C. Bryden – Critical Care Department, Shefzeld Teaching Hospitals NHS Foundation Trust, Northern General Hospital, Shefzeld, UK.

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