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Mind Over Matter? The Hidden Epidemic of Cognitive Dysfunction in the Older Surgical Patient

O’ Brien, Helen MRCPI; Mohan, Helen MRCPI, PhD; Hare, Celia O’ MRCPsych; Reynolds, John Vincent FRCSI; Kenny, Rose Anne MD, FRCP

doi: 10.1097/SLA.0000000000001900

Objective: The aim of this study was to highlight the vulnerability of the aging brain to surgery and anesthesia, examine postoperative cognitive outcomes, and recommend possible interventions.

Background: Surgeons are facing increasingly difficult ethical and clinical decisions given the rapidly expanding aging demographic. Cognitive function is not routinely assessed either preoperatively or postoperatively. Potential short and long-term cognitive implications are rarely discussed with the patient despite evidence that postoperative cognitive impairment occurs in up to 65% of older patients. Furthermore, surgery may accelerate the trajectory of cognitive decline and dementia.

Methods: An electronic search was conducted using Pubmed/Medline. References from selected studies were cross-referenced and relevant articles retrieved. Data were summarized in a narrative format.

Results: There is a hidden epidemic of cognitive dysfunction in the perioperative setting. Up to 40% of patients who develop postoperative delirium (POD) never return to their preoperative cognitive baseline. POD can lead to postoperative cognitive dysfunction (POCD), a more prolonged cognitive impairment associated with longer length of hospital stay and cost, premature withdrawal from the workforce, and greater 1-year mortality. Standardized perioperative cognitive assessment is needed to enable progress. Improving outcomes will depend on a multifaceted approach, including correction of modifiable preoperative risk factors and prompt treatment of POD. Risk factors are discussed and possible interventional strategies are presented.

Conclusion: Closer preoperative collaboration between surgeons, geriatricians, and anesthetists will enable identification of complex at-risk older patients. A paradigm shift in the approach to management of the older surgical patient is critical to improve postoperative cognitive outcomes in modern surgery.

*The Irish Longitudinal Study on Ageing (TILDA), Trinity College Dublin, Dublin, Ireland

Mercer's Institute for Successful Ageing, Department of Medical Gerontology, St. James's Hospital, Trinity College Dublin, Dublin, Ireland

Department of Surgery, Cork University Hospital, Wilton, Co. Cork, Ireland

§Department of Surgery, St. James's Hospital, Trinity College Dublin, Dublin, Ireland.

Reprints: Helen O’ Brien, MRCPI, The Irish Longitudinal Study on Ageing (TILDA), Lincoln Gate, Trinity College Dublin, Dublin 2, Ireland. E-mail:

Financial support was provided by the Atlantic Philanthropies, the Irish Government, Irish Life PLC, and the Health Research Board. These funders had no involvement in analysis and preparation of this paper.

The authors report no conflicts of interest.

Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.