Question re Post-Op Amnesia

Homesick Gypsy · Dec 30, 2005

Me again. I've been doing some research and found a term that describes what I've been experiencing: "Postoperative Cognitive Dysfunction". Apparently it's more common than I knew and quite a few studies are being conducted. Even though I have no other symptoms of menopause, my doctor has placed me on 1 mg. estradiol tablets to see if it helps. Can't tell much of a difference.

Although this seems to affect elderly (age 60 and above) patients more often, it has been seen in patients of all ages (I'm 50 and in good health). In also reviewing my medical records and itemized bill, I'm wondering if part of it might have to do with my hemorrhage and subsequently being given hetastarch..... One guess is as good as another.

Here's is the ASA Newsletter, February 1999 (emphasis mine):

ASA NEWSLETTER February 1999 Volume 63 Number 2

Does Anesthesia Leave Some of Our Patients With Prolonged Postoperative Cognitive Dysfunction?

Joachim S. Gravenstein, M.D.

We begin the era of the brain. The stage was set last year by two important publications that focused on cognitive dysfunction after anesthesia and surgery in the elderly. A clinical study by Moller and coworkers appeared in The Lancet1 and Dodds and Allison published an excellent review article in the British Journal of Anaesthesia.2

Because cognition may decline with advancing age, Moller et al. studied some 1,200 patients who were 60 years of age and older, assuming that if anesthesia and surgery did indeed affect mental functions, it should be most readily detected in the elderly. The investigators administered psychological tests before the operation, within a week postoperatively and again approximately three months later. In all patients, general anesthesia lasted at least two hours. Cardiac and neurosurgical patients were excluded as were patients who failed to meet the study criteria. Volunteers of comparable age, but not undergoing surgical treatment, were given the same psychological tests at the same intervals to serve as controls.

The investigators detected new cognitive dysfunction in the first postoperative week in some 25 percent of patients. After approximately three months, close to 10 percent of patients showed measurable cognitive dysfunction. This differed significantly from the 3-percent decline in cognitive function observed in the control population over the same time span. The data confirmed the hypothesis that older patients were at greater risk; patients over 70 years of age were twice (14 percent) as likely as those in their 60s (7 percent) to show prolonged cognitive difficulties. The authors rejected the hypotheses that hypoxemia or hypotension during surgery or during the first three postoperative days can be linked to postoperative cognitive dysfunction.

The review article by Dodds and Allison brings this study and many others into focus. The authors cite 89 papers and discuss the history of published concerns about cognitive difficulties after anesthesia. Remarkably, such concerns were expressed with growing frequency only in the last 50 years, perhaps triggered by Bedford's report in 1955 in The Lancet that some elderly patients develop dementia after general anesthesia.3 Dodds and Allison examined publications exploring the mechanisms that might contribute to cognitive dysfunction after anesthesia, among them: drug effects; physiologic changes during anesthesia such as hypoxemia, hypotension and hypocarbia; neurotransmitters; the cholinergic system; and genetic factors. They also reviewed studies that failed to find prolonged postoperative cognitive problems or that compared regional with general anesthesia. Dodds and Allison concluded their review with the following categorical statement: "There is no debate as to whether or not postoperative cognitive deficit exists. It is common and persistent ..."

We may accept as inevitable the frequent psychological disturbances that affect elderly patients in the early postoperative period. Too many mechanisms come to mind: the slow elimination of central nervous system-active drugs used during and after the anesthetic, the effects of metabolic and hormonal disturbances, sleep deprivation, pain and the disorienting effect of the strange hospital environment. The observation, however, that many elderly patients and presumably some younger adults as well show signs of cognitive disturbances three or more months postoperatively present us with new and urgent questions: How many of these disturbances fail to resolve with time? Can such problems push some elderly patients prematurely into dependency? Can we preoperatively identify patients at risk for late postoperative cognitive disturbances? The literature and common sense suggest that patients with pre-existing psychological dysfunction are at higher risk. Can we prevent the problem with the help of different perianesthetic measures? Are the problems even related to anesthesia, or do they have to do with the impact of hospitalization, drugs unrelated to anesthesia, disease processes or changes in living brought about as a consequence of the surgical disease? Whatever the answers to these questions, we should recognize that there is no postoperative complication more frequent and of longer duration than postoperative cognitive dysfunction in the elderly.

Anesthesia is not limited to "putting them to sleep and waking them up again." Over the years, anesthesiologists have assumed responsibilities in the intensive care unit and for pain management for all hospital patients. It is time for the specialty to become actively involved wherever possible in preventing and treating postoperative cognitive dysfunction. Such involvement will call for research and active care of the affected patient.

We may draw a parallel to pain management. While we started out treating only wound pain, we now treat pain of many different origins. While we started out worrying only about early postanesthetic confusion, we now should recognize that late postoperative cognitive dysfunction demands our attention. At this time, the ASA standards for care and monitoring do not even mention the brain, the very organ we depress so skillfully to relieve anxiety and pain. In the future, it is likely that ASA's standards for care and monitoring will include statements about our responsibilities in preventing postoperative dysfunction of the central nervous system and, where that fails, in monitoring and caring for patients with postoperative dysfunction of the central nervous system.

References:

Moller JT, Cluitmans P, Rasmussen LS, Houx P, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet. 1998; 351:857-861.

Dodds C, Allison J. Postoperative cognitive dysfunction in the elderly surgical patient. Brit J Anaesth. 1998; 81:449-462.

Bedford PD. Adverse cerebral effects of anaesthesia on old people. Lancet. 1955; 2:259-263.

--------------------------------

Joachim S. Gravenstein, M.D., is a Graduate Research Professor Emeritus, Department of Anesthesiology, Shands Teaching Hospital, University of Florida, Gainesville, Florida.

mwbeah · Jan 2, 2006

I am 3 weeks post-op from abdominal hysterectomy with BSO. I had an excellent surgical outcome, despite nothing going as planned and lots of surprises. My only complaint is that the gas passer slipped me something in pre-op before I finished my pre-anesthesia interview. I have very little memory of my four days in the hospital, and lots of memory lapses since being home.
I know that low estrogen can cause "brain fog" but at this point I have no other menopausal symptoms. I don't feel like I'm in a fog, just can't form a memory. I had an adverse reaction to the Vivelle patch put on at the hospital so am waiting for surgery drugs to clear my system, and also waiting for menopausal symptoms to appear. I have a lot of "belly fat" so assume I am receiving adequate estrogen from that at the moment.
Can the after effects of anesthesia last this long, or should I be concerned? I saw my surgeon one week post-op to remove staples and he brushed off my concerns. I don't want to be a drama queen, but am concerned that maybe I have a problem with what was given me, and possibly should be aware of it in case of future surgeries.
Any and all thoughts are welcome.

If I were you I would research the literature involving the effects of hysterectomy on memory (some sources quote 67% of women have memory deficits after this procedure).

Mike

athomas91 · Jan 3, 2006

the only thing that article continued to refer in regards of measuring "cognitive dysfunction" was psychological testing....were i to have time i would read further into the study - it doesn't cite in the article what type of study it was and therefore it is impossible to identify any validity problems. it does state the authors refute the belief that hypotension etc.. contribute - but it doesn't state how or why they feel they came to that conclusion...

your last post refers to a hemmorhage - but in previous posts you speak of how surgery went well and without complication...you also stated you are 50 and in good health - but you earlier stated that they couldn't do an epidural due to your weight...an even later post mentions blood in your ear - if you had abdominal surgery and you found blood in your ear - it stands to reason that the blood in the ear would be a huge concern - where did it come from....

perhaps i am just reading into the differing posts too much - but there seems to be a number of contradictions as well as complications that just keep adding on.....

mwbeah · Jan 3, 2006

the only thing that article continued to refer in regards of measuring "cognitive dysfunction" was psychological testing....were i to have time i would read further into the study - it doesn't cite in the article what type of study it was and therefore it is impossible to identify any validity problems. it does state the authors refute the belief that hypotension etc.. contribute - but it doesn't state how or why they feel they came to that conclusion...
your last post refers to a hemmorhage - but in previous posts you speak of how surgery went well and without complication...you also stated you are 50 and in good health - but you earlier stated that they couldn't do an epidural due to your weight...an even later post mentions blood in your ear - if you had abdominal surgery and you found blood in your ear - it stands to reason that the blood in the ear would be a huge concern - where did it come from....
perhaps i am just reading into the differing posts too much - but there seems to be a number of contradictions as well as complications that just keep adding on.....

You know that anesthesia gets blamed for everything.................. :clown:

Homesick Gypsy · Jan 3, 2006

It seems as though some of the people responding are very defensive, perhaps rightly so. I'm not blaming anyone, including anesthesia. I'm just trying to find some answers. The article said there were 89 papers and that doctors were aware of the situation and research was being done to see if something can be done before surgery to minimize the problem. Besides my personal experience, I find it all very interesting. I'm heartened by the fact that surgical outcomes have become so good, that now research is being focused on the more subtle issues.

Because of the memory problems, some issues are just coming to light from my daughter and friends that were there. The blood in my ear was never mentioned in my medical records. My daughter thought I might have scratched myself or something. I am overweight yes, but otherwise in excellent health - low blood pressure, low cholesterol, no heart or lung problems...

Because of the vasculature that had wrapped all around the huge fibroids, I lost quite a bit of blood. I was given hetastarch and my crit kept rising so I didn't need a transfusion, although blood was typed and set aside, according to my records. There were complications during the surgery as far as some unexpected findings once the surgical field was clearly visible, but my outcome was excellent. My surgeon is very good at what he does.

Yes, both ovaries were removed but I have had zero symptoms of menopause. No hot flashes, no sleep disturbances, nothing. Except for the memory problems, I haven't felt this good in years. It's funny how much pain and discomfort we can learn to put up with.

In consulting with my doctor, he gave me a prescription for 1 mg. estradiol tablets, even though I have no other menopause symptoms. It has only been two weeks so far but I can't tell much of a difference. Perhaps in another week or so I'll be able to see great improvement. If the estrogen doesn't help, my doctor will refer me to a neurologist to see if there might have been something that happened during the surgery. My dentist is also a board-certified anesthesiologist and told me that he suspects perhaps something did happen, and that sometimes it's so small and subtle, even the anesthesiologist can miss it. If it turns out that I had a mini-stroke or some other form of permanent short-term memory problems, then I'll learn to deal with it. I'm just trying to explore all the possibilities before I just give up. Besides, all the mental gymnastics are good for my brain....:rotfl:

I'm not angry or blaming anyone. I just thought you might find the article as interesting as I did.

jenniek · Jan 4, 2006

The blood in my ear was never mentioned in my medical records.

The blood could actually be betadine from being prepped, often when it dries it looks like blood. Or if you had a central line placed in your neck, it could easily be from that.

As far as your surgery, it sounds like less than routine and pretty intensive. If you hematocrit was low, that could affect your memory due to less oxygen carrying capacity.

There are many factors, and I doubt we could solve the mystery given that we can't see your nor do we have access to your records.

makeusleepy · Jan 4, 2006

If you really want to find out what happened during your surgery in terms of anesthesia and want to know if anesthesia is to blame for your current memory problems....why don't you contact the Anesthesia provider or group from your surgery.

We don't know you, we don't know what happened during your surgery and every person responds so drastically different to anesthesia it is impossible and irresponsible for us to say, "oh, you had a TAH, this is what happened."

No offense but I think you'd be better off going to the source.

Homesick Gypsy · Jan 5, 2006

I was wondering if mwbeah would be so kind as to point me in the direction of the sources you mentioned as something like up to 67% of women having a hysterectomy have cognitive dysfunction following surgery. I have been unable to find much and would appreciate a point in the right direction.

Thanks.