I took my WW to the orthopedic clinic yesterday for knee pain. She tore her ACL in a skiing accident about 20 years ago and, as a result, had two separate surgeries on that knee within two years of the accident. Her x-rays now reveal significant osteoarthritis with bone on bone contact. The physician gave her a cortisone injection which might buy some time before she needs a knee replacement.
She is now 57 with a formal dx of EOAD (Mayo is now calling it Alz) in 2005. We know (in retrospect) that she had signs/symptoms as early as 2001. She had a triple coronary bypass in 2004 which really seemed to worsen her cognitive problems. Since then I've learned that there is an ongoing debate in the medical/cardiac community as to whether or not the surgical stress of CABG causes dementia (or at least hastens its progression).
In talking with other caregivers at our local dementia support group, I've heard many stories of a turn for the worse in their dementia LOs that underwent non-coronary surgical procedures (after having a formal dx of dementia). I've even heard it happen in cataract surgery - where the patient is not even "put under".
Do any of you have experience with this happening in your LO? I'm really scared to subject her to any surgery, before it's absolutely necessary, that will worsen her dementia. Thanks for your input.
From experience I have had, people with or without some dementia do suffer some degree of dementia following the anesthetic. I have a friend 77, without dementia had a extended hospital stay with a serious illness and since then he has trouble focusing. His wife said he goes from one small job to another, without finishing anything. My Mother had a broken hip and she was thorouly confused following the repair, although eventually she improved. I would hate to have my H go through surgery unless it was an emergency to relieve pain. None of his Drs. want him to undergo back surgery to relieve his severe pain from stenosis. I don't know what we will do when he gets so bad he can no longer walk. Do you take a wild chance it will help him stay on his feet? I cannot manage him at home if he is unable to walk. The knee situation sounds similar to the stenosis in seriousness.
My DH had a total knee replacement in '95. We saw a bit of cognitive impairment following that, but he pretty much returned to baseline. He had retired in '92, but continued to work under contract until 2000. He was still quite functional.
We moved out of state in 2001, and some few incidents of confusion were overlooked, attributed to "unfamiliarity."
In 2003 we brought my folks to live with us as Dad had AD, and Mom had ovarian cancer. I had spent alot of time away from home to care for them, so it made sense to bring them here. Between 2003, and Mom's passing in July 2005, my kids say they were increasingly frustrated with their Dad's forgetfulness. AND his argumentativeness. My Dad had been placed before Mom died, and DH had put off having a torn rotator cuff repaired until my journey with the folks was over.
In early Sept. 2005 DH had the surgery. He was totally whacked. Had to stay over another night due to his craziness. He was totally noncompliant with MD instructions, and just really NOT himself. His post op behavior, after a few weeks led to tests, and scans, and an eventual diagnosis of moderate AD on November 1, 2005.
DH's PCP, Neuro, and Ortho docs all recommend NO KNEE REPLACEMENT surgery after witnessing the post op cognitive decline when his arm was done. He has been bone on bone, complaining of pain for years, but the doc had explained that the arm surgery would be necessary prior to the knee surgery. DH would have had to rely alot on arm strength in the initial post op knee period. Had he not had that arm surgery first to show us this cognitive result I doubt my DH would be able to walk at all.
Isoflurane, an inhaled general anesthesia is the definite one to avoid. But even though the docs said regional anesthesias are available, the surgical stress on the body can be just as detrimental.
DH was probably a stage 3 prior to the shoulder surgery, but he came out a stage 5.
My husband was mentally unclear for more than a week after minor prostate surgery, just before he was diagnosed with Parkinson's. I don't think it had a permanent effect on him, but it was a tough time. I thought that the effect of anesthesia was particularly an issue with Lewy Body Dementia, which is now his diagnosis.
Pam (husband age 63 diagnosed with Lewy Body Dementia in 4/08)
I've heard of some new procedures to do with knee replacement--less extensive thus less stressful, but effective. Might be worth checking out options. Hubby had carpal tunnel done a few years before Dx but well after Mental Illness was diagnosed. Some VaD symptoms showing then but we didn't know. They used a very light anesthetic (MAC)(?) Didn't seem to have any negative effects--same level of disfunction before and after.
I just did a pretty thorough search for a friend with AD who was considering knee replacement.
I had been under the impression that the idea that anesthesia could cause dementia was fairly new and that few studies had been done. This is not true. People have been studying this possibility for more than 50 years.
The risk of developing (or exacerbating) long-term cognitive dysfunction from surgery is relatively low. For example, only ~5% of elderly patients who underwent total knee replacement had any cognitive decline (compared to the pre-surgery baseline) six months after surgery. At six months post-surgery, there was no difference between patients who received general anesthesia and those who received regional anesthesia. (This was also true for other types of major non-cardiac surgery.)
Many researchers do not believe that there is ANY long-term effect, lasting more than a year. Most studies have failed to compare surgery patients with non-surgery controls. When the effect of simply aging is considered, surgery patients and non-surgery controls have the same level of cognitive decline 1-2 years later.
Short-term cognitive dysfunction is relatively common after major surgery. For example, in a large (225 patients) study of people ≥ 65 years of age undergoing non-cardiac surgery, 15% had post-operative cognitive dysfunction (POCD) in the two days following surgery. The researchers looked at many factors that could be causing the POCD, including preoperative level of cognitive and daily functioning (that is, the level of dementia before the surgery), preoperative medications, duration and type of anesthesia, and adverse events. Only post-operative analgesia (pain control) was associated with the development of POCD.
Some of the risk factors for developing POCD can be prevented, controlled, or treated.
For example, anticholinergic drugs should be avoided. Diazepam should not be used as a pre-operation medicine. Benzodiazepines and meperidine should not be used for pain control after the surgery.
Patients who develop delirium after surgery are more likely to develop POCD. Factors associated with the hospital environment, such as sleep deprivation, immobility, dehydration, sensory overloading (bright lights, noise) and lack of a home environment, have been linked with delirium. Delirium can be decreased by 40% when intervention strategies are used to reduce these risk factors. Some studies have found that pre-surgery psychiatric counseling can help. Post-surgery interventions include making sure that patients are oriented and hydrated, that they are up and walking as soon as possible, that they are using their hearing aids and vision aids, and that they avoid the use of sleep medications. Family members can help minimize or prevent delirium by making sure that a loved one is not left alone for long periods, especially when the loved one is coming out of anesthesia. They may want to arrange to stay overnight at the hospital -- this way someone who knows how the patient normally acts can quickly alert hospital staff to any changes in behavior. Making sure that the hospital room is well lit and that curtains are open during the day can help patients maintain a sense of time and get back to a regular schedule of sleeping at night and staying awake during the day. It can help if the patient is given a warm drink (milk or herbal tea), relaxation tapes or music, and back massage at bedtime. Make adjustments to the patient's schedule to allow sleep (e.g., rescheduling of medications and procedures). Family members also can make sure that eyeglasses and hearing aids are worn. And familiar objects from home such as a favorite sweater, blanket, pillow, books, or family photos can also help patients maintain orientation and awareness while they are in the hospital.
If the patient already has dementia before surgery, the risk of developing delirium after the surgery is somewhat higher. Delirium can be significantly reduced by using techniques that help orient the patient and keep the patient mentally stimulated. For example, use a bulletin board or white board with the names of care-team members and the day's schedule. Hospital staff and family should talk with the patient to help the patient remember where s/he is and why. (The greater the level of dementia, the more often this should be done.) In addition, staff and/or family should engage the patient in cognitively stimulating activities, preferably three times daily (e.g., discussion of current events, structured reminiscence, or word games).
If at all possible, avoid the use of physical restraints, malnutrition, adding more than three drugs, the use of bladder catheters, and post-surgical complications, especially infections. Also keep an eye out for post-surgery thyroid hormone and/or vitamin B12 deficiency.
continuing, since this site does NOT like my long posts ...
A good rehabilitation program can also help. This includes twice daily physiotherapy and daily activities, more intense nursing care (which could be provided by family), and common rehabilitation interventions such as occupational therapy and speech therapy.
(The only type of surgery that has been reliably shown to make dementia worse is major cardiac surgery. However, this is probably due to the adverse effects of cardiopulmonary bypass on the brain, not to the anesthesia itself.)
I know isoflurane has been identified as a "bad guy", but the studies that compared its use to other anesthesias did not find any significant differences. Concerns are based on studies that have been done with cell cultures and animal models, and they are often genetically engineered, so there isn't a whole lot of basis for being very confident that they actually model the human brain.
All of that said, I'd opt for local/regional anesthesia, if the anesthesiologist is experienced in using that for this type of surgery. It's used pretty commonly over in Europe for knee replacement.
I'd also, frankly, look into whether knee replacement really really really is needed. The risk is not as great as many people believe, but there is still a risk. One of the people who post over on "the other site" had it recommended to her -- she's an RN and other than the knee pretty healthy -- and she opted for a brace and physical therapy, if I recall correctly. I'll go look, see if I can find the details.
Excerpts from the RN's comments about knee replacement:
If you decide to move ahead with surgery, have Neuro follow along with you while in the hospital and have him work with the surgeon re medication needs and their effect if any.
Now, surgeons LOVE to perform surgery. That is their thing. But, since this is not an emergency and is elective, you have plenty of time to discuss this with Neuro and even get a second surgical opinion.
Very often, other steps or alternatives can be taken. There are knee injections which are very "high tech" that can offer much relief without surgery. There is bracing.
Having the surgery is one thing; being able to tolerate the post-op pain and the effect of very necessary pain medication is a second. Again, Neuro input could be invaluable in the approach to medication.
The need to be able to COMPLETELY AND FULLY tolerate the PT and OT psychologically is crucial to the success of the procedure. You may do very well with this, but discussing it with Neuro is once again, important.
All the more reason to sit down with Neuro and obtaining a second opinion of another Ortho to see if something simple can be done.
I too have very severe knee issues and will need to have knee replacement. My knees are in far, far worse condition than yours, (not to negate what you are feeling or to try to go "one up").
What may be a real possibility is that the fluid, (effusion) in the joint may be the reason for the severity of the pain. The fluid can be aspirated and removed. I had this done once under fluoroscopy in the doctor's office and I didn't feel a thing!
If there is something they can do lesser than a full-on knee replacement, that option or those options should certainly be considered.
My good friend Helga had AZ, but was functioning at about a level 4 in assisted living. Broke her hip, had the operation to repair it (which was of course needed), came out, wheelchair bound and much much worse. Serious Stage 6. A lot of us on this board have encountered similar things, irrespective of the studies. Do some searches on anesthesia.
I would of course have my husband treated if he broke something. Otherwise, no.
Before my husband's surgery for a partial knee replacement started his o2 sats dropped into the 70's (high 90's normal). They proceeded anyway and he wound up on a vent for a short while. Mental status really dropped. 2 years later he needed a total knee replacement. This time I spoke with anesthesia-they listened to me-and he did not receive general anesthesia. He was not compliant with rehab and wound up on a psych ward and then placement. My experience with elective proceedures makes me say-avoid them if possible. A fracture is another story.
My DH had an emergency colectomy while in stage 2 of AD. During the hospital stay, he was given IV pain killers after surgery and immediatley started with his first hallucinations. I believe narcotics after surgery cause just as many problems as anesthesia. After his release from the hospital he was in stage 4 of AD.
One year later he needed a total knee replacement. Thankfully, a wonderful surgeon did the procedure with a nerve block and Ultram tablets afterward for pain. There were no side effects, no increases in AD symptoms and no decreases in cognition.
Physical therapists claimed his recovery was faster than those who had general anesthesia.
The dementia symptoms/anesthesia connection has been discussed on various threads on this board. It is a very real concern. You can do a search at the top of the page - type in "anesthesia", and make sure the "comment" circle is filled in. There is probably too much to look through, so for a more condensed version, go to the home page - www.thealzheimerspouse.com - click on "previous blogs" on the left side and scroll down to # 117 and #118. Blog #117 includes links to various informative articles on the subject, and #118 is an account of an experience I had with prolonged anesthesia.
Thanks for the blog links. It's always nice to start a new discussion as this brings new people/ideas/experiences into our group.
Sunshyne,
I can assure you that I will wait until there are no other options. PT was discussed yesterday. She really can't follow directions anymore. There's no fluid/effusion in her knee joint. It's just bone on bone. When we decide on surgery we will consult with Mayo regarding anesthesia. Thanks for all your research.
My hb had prostate surgery in February. The anesthesiologist said he wouldn't consider general anesthetic because it would make his dementia worse; so he had the surgery w/local anesthetic and recovered physically rapidly.
iggy, for cases like your wife's, there are fluids that can be injected into the knee, and also oral supplements. The injectable fluids contain hylan or hyaluronan. Hyaluronan is one of the major molecular components of joint fluid, and it gives the joint fluid (synovial fluid) its viscous, slippery quality. The high viscosity of synovial fluid allows for the cartilage surfaces of joints to glide upon each other in a smooth fashion. Hylan is a cross-linked hyaluronic acid derivative. Oral supplements may contain hyaluronates, chondroitin sulfate, and/or glucosamine.
Some of the earlier clinical trials of the first hyaluronan products produced inconclusive results. That may have been due to the design of the trials (for example, they used different molecular sizes of hyaluronan, different injection programs, different lengths of follow-up, etc.) Success also apparently depends on where the injection is done, which apparently has to be adjusted according to the severity of the problem.
All of the most recent studies I've found on the newer treatments look pretty promising. Not every patient responds well, but a pretty high percentage do.
My DH had knee replacement around '96 and i can tell you i have associated that procedure and the large amounts of morphine drips to his dementia onset. he was out of it for several days on themorphine so i dont think its an optional choice for him now or 'later' which is of concern. the physical therapy with the machine they brought to the home to make his leg move automatic all day was super painful for him to endure as well. he did well and was up and about 6mos after. then the yr llater he had a hair replacement done which involved injecting local anesthetic as well. then he really got noticeably worse as far as dementia - i think anethesias and surgery of any nature can makes things progress. divvi
Two months ago my DW fell and got a torn rotator cuff. We saw the doctor again today, and decided not to do any surgery. He agreed that anesthesia seems to make dementia worse. As long as she is able to function reasonably well, we will not do anything further. Ibuprofen seems to work.
My DH also fell last summer (a couple of times) and has a torn rotator cuff. Doctor and I decided no surgery. He functions very well and doesn't complain often.
Marsh, I'm so sorry to hear about your wife's injury. Also, your husband's injury Vickie. It is hard enough dealing with AD and the other illnesses our spouses have without having injuries on top of it! Sometimes they don't even feel the pain that they are in.
My DH had a microdiscectomy October 1. The pain with his herniated disc (L5-S1)had been increasing over two years of trying all the 'other' things. Eventually his pain level was 10 all the time and only controlled with hydrocodone. I had anesthesia hesitations, but felt we had no choice by this time. He did not not need post-op pain meds except for one dose. I did not immediately notice any loss. I did notice that, over a the 2-3 weeks before we figured out alternate ways for him to do household tasks, there was a decline in cognitive function. I attribute that to too much television and not enough tasks to keep him active mentally as well as physically. He was walking during this entire time...2-3 miles a day...but while he felt mentally better, it did not seem to affect his decline in function.
I will be having Carotid Artery surgery next month and I have told my surgeon that I do not want the anesthesia you inhale. He told me to tell the anesthesologist..... so is there a name for the type I want or is just local/regional? Thanks for your help.
Regional/local is best, but a general anesthesia that is administered intravenously is okay.
Meds that are used before and after the surgery can be risk factors, too. Anticholinergic drugs should be avoided. Diazepam should not be used as a pre-operation medicine. Benzodiazepines and meperidine should not be used for pain control after the surgery.
Jean, ask to speak to the anesthesiologist the day or the week before the operation. I mentioned that I had issues before my major surgery several years ago to the surgeon and he fixed it so the anesthesiologist called me at home to discuss them. I'm one of those people who need more than the normal amount of anesthesia. I've been known to cry, talk and fight with the doctor when I'm supposed to be out. I once told the anesthesiologist "I'm still awake" when the nurses started stripping me for surgery.
He had no problem with discussing it with me well before the operation and thanked me for warning the surgeon that there might be a problem.
Remember that anesthesiologists not only put you asleep, they also are the ones who need to wake you up again.
Starling, I THOUGHT I had replied earlier but I must have goofed. I am 4.10 and weigh 98lbs I have always had to have more anesthesia than they think. When I had cataract surgery on my right eye I know they gave me 3 shots through the IV in my hand. When I got the left eye done I asked if the had any notes from the first one and they said I had been given 3mg then another one. When the doctor was doing my left eye the nurse said something to the doctor and he said "She's jumping". I told him "she's jumping because she can feel it". I don't know if they gave me more anesthesia or deadened my eye more but I didn't feel anything after that! All this was in the past month and so far so good except for dry eye in my left one that one is about to drive me crazy. I think I am using moisture drops by the gallon. LOL
Jean, my ophthalmologist recommended Thera Tears Nutrition which is a combination of flax and fish oils. It has really helped. Takes 2 or 3 weeks, though.
My ophthalmologist recommended Restasis and Tears eyedrops. Do they all have the flax and fish oil in them? I have been taking fish oil and flax seed capsuls after someone on this board recommended it. I have used the Restasis for a couple years. $$$ He said I could use the same capsule a couple of times to save on $$$.
1. aqueous deficient dry eye - your eyes are not producing enough tears. 2. evaporative dry eye - your eyes produce enough tears, it's just that, for one reason or another, they don't stay on the eye long enough.
Restasis (made by Allergan) is a cyclosporine emulsion intended to treat an aqueous deficient dry eye. It is NOT an artificial tear - although it is "wet" and anything "wet" on the eye will make it feel better for a short period of time. Remember, there are different types of "dry eye" and Restasis is not designed to treat all of those types. And it does take 2-4 months of treatment to determine if Restasis is making any difference.
lmohr - How long can you get a vial of Restasis to last? I have emptied/counted the drops in numerous vials and have found that each vial contains about 11 drops +/- 1. The prescribed dosage is 1 drop in each eye twice a day. At 4 drops/day you should be getting 2.5 days/vial. If any of you are not getting 2.5 days/vial let me know and I will expound on this further (it used to be Allergan's dirty little secret).
TheraTears products (Advanced Vision Research) are VERY well thought of in the Optometry/Ophthalmology community. Dr. Jeff Gilbard is a well-respected M.D./Research Scientist and his products are based on sound science. They are available at most discount stores and I see that there is a on-line store on his web-site.
A mixture of Omega-3 sources has been found to be superior to either fish or flax alone.
www.theratears.com
Here is another community discussion web-site for those of you with significant dry eye issues:
I believe my dry eye is the result of the cataract surgery and I am hoping it will be gone when my eye has healed completely. I did buy some Sestayne Ultra which seems to help more than the drops the surgeon gave me. I have to go out again this afternoon so I will stop at the drugstore and see what the pharmacist comes up with. Thanks for all the info.
Iggy - I use the restatious - 1 in each eye twice a day - until they are gone and that is more than 1 day. I have been on them a significant time and can't tell for sure if it helps or not. I am not having as much pain in my eyes when I use them. The omega 3 you mentioned - is that to take orally or as drops in the eye.
I mentioned earlier I can no longer cry and I attribute that to dry eye. However, in the spring when I first go outside in the wind my eyes will hurt so much I have to squeeze them shut and there are tears then. I have not had that problem for a while and thought maybe the fish oil and flax oil were helping also.
Systane Ultra (Alcon) is a very good artificial tear. If there's one mistake that most patients make with ATs is that they don't use them often enough - especially in environments with low humidity. Twice a day is NOT often enough. One drop/eye every couple of hours is more like it.
With all due respect to my pharmacy colleauges, they don't know much about dry eyes (unless, of course, your son/daughter is a pharmacist :>)
Jean21 - are you still on your post-op drop regimen? If you are, most post-op drops (antibiotics, pred-acetate, and topical NSAIDs are preserved with BAK. BAK (benzalkonium chloride) can cause some transient corneal surface irritation which would mimic/exacerbate dry eye symptoms. Using non-preserved artficial tears is the best way to treat your symptoms. Systane Ultra is available in a non-preserved formulation. It's a little more expensive, but worth it.
If you can no longer cry, you probably have a severe aqueous deficient dry eye. The tearing that you're experiencing in the wind is called reflex tearing. It's best treated by wearing eye protection (glasses/sunglasses/wrap-around sunglasses) and putting a drop of AT in both eyes just before going outside.
Glad to hear you're using the Restasis vial until empty. There is still a fair degree of controversy within the eye professions/literature as to how effective Restasis actually is. If you think it's working for you - that's great.
Omega-3 is always an oral supplement. There are about a zillion different formulations. I have tried that Icelandic brand formulation - I was belching fish gas the rest of the day. There are enteric-coated formulations that help with the fishy after-taste/belching. I haven't tried the TheraTears formulation (it's actually part of a nutrition packet).
Iggy, I am in the process of weaning myself off the cortisone drops (Pred Forte). Right now I am on the 3 drops per day for a week then I go to 2 then 1 then STOP!!! I have one more appointment with the surgeon next month. At least I am assuming it is one more. I am hoping everything will be taken care of before I get the carotid surgery. Like I always say "Getting old is not for old people".
Many thanks Iggy. I am going to still hang in with the restatious along with the eye drops. Doesn't seem to be anything better. I am going to try and use the other drops more often. I bought new wrap around sunglasses this spring at $450. for no line bifocals and I love them. They were worth every penny. Going to check out the Omega 3.
Iggy, I really don't know what I am having, my artery if 70% blocked if that makes a difference. The surgeon mentioned something about putting a patch in instead of just sewing the edges together so I am guessing it wouldn't be Roto Rooter! I think I could have waited until next year to have the surgery but I thought it was better to have it now while DH is still okay. By the way, as I'm sure you know the Pred Forte is a steroid not cortisone. I don't know how I came up with that...are they sure AD isn't catching. VBG
iggy, thanks for all the information. I think I read on another thread that you were an ophthalmologist. Is that right? No ordinary person would have that much information...... unless it's our researcher Sunshyne <grin>
My dry eye problem is that I don't produce enough lubricating tears. I can still cry but apparently it's not the lubricating kind of tears because it irritates my eyes. I'm having pretty good luck with Systane Ultra and Thera Tears Nutrition capsules but now I'm wondering if I didn't give Restasis enough time. It just seemed that my eyes hurt and were more dry when using it. After 6 weeks I discontinued Restasis and they seemed to get better.
Thanks, Joan, for letting us get off subject sometimes. We just learn so much.
I'm an optometrist and am on the staff of an ophthalmology clinic. Always happy to address "eyeball" questions and concerns. If you weren't comfortable after 6 weeks of Restasis therapy and things seemed to get better after discontinuing it - you gave it enough time and you did the right thing. The clinical success rate for Restasis is less than 50%.
You're right - Sunshyne is the best when it comes to research!
Joan- You might want to go back 16-17 posts to bluedaze and jean21 comments on dry eye and start a "Dry Eye" thread. We hijacked this one really well!! This would allow us to go back to the Surgical Anesthesia topic.
There has been so much written here about loved ones and their experiences with surgeries and anesthesia. Type in to the search box either surgery or anesthesia.
daughter called and her classes are cancelled due to flooding so I gotta go. otherwise I'd write more about our experience.