By Maya Menashe, Science and Technology Editor
Patient is an elderly man with a history of mild cognitive impairment, the stage between typical thinking skills and dementia, who presented for elective spine surgery. Medical history is obtained from his wife at bedside. Postoperatively, his wife reports a sudden and significant worsening of cognitive function, noted immediately after his procedure. He now demonstrates extreme confusion, frequent mumbling and fluctuating, dementia-like symptoms that vary from day to day.
This summer, I had the privilege of observing and assisting Dr. David Rahimian, a neurologist who specializes in stroke care, at St. Francis Hospital. Each morning, I joined him as we moved from inpatient rooms to the emergency department, caring for patients battling some of the most complex neurological conditions, such as myasthenia gravis, Sjogren’s syndrome and locked-in syndrome. Being involved in patient care in this setting taught me not only about the clinical reasoning behind complex cases but also about the importance of recognizing how disease affects the patient and family beyond the hospital.
The patient’s wife, who was understandably heartbroken by her husband’s sudden change, told Dr. Rahimian and me about the man he was before: a talented guitarist who loved bringing joy to his surroundings through music, a former undercover narcotics agent in New York City and a devoted grandfather. Now, as he lay in a hospital bed wearing a neck brace, he seemed almost unrecognizable compared to the life she was describing. But despite his tragic state, the patient looked at Dr. Rahimian and me with a smile that extended from ear to ear, which signified that his prior life is still within him. Stories like his can remind us about the power we have to protect our fragile minds.
Many studies and trials have shown that maintaining good health is incredibly important for reducing the risk of cognitive decline as we age, both in general or postoperatively. Taking care of physical health, whether by limiting the use of alcohol, getting adequate sleep or being mindful of the food we consume, proactively supports cognitive function. For example, the Systolic Blood Pressure Intervention Trial Memory and Cognition in Decreased Hypertension (SPRINT MIND) study found that adults 50 years or older who were at high risk for cardiovascular disease and received intensive blood pressure control had a reduced risk of developing mild cognitive impairment, which is usually a precursor to dementia, over five years of treatment. Another randomized and controlled trial, called the Advanced Cognitive Training for Independent and Vital Elderly (ACTIVE) trial, showed that participants who underwent cognitive training, specifically in areas of memory, reasoning or speed of processing, experienced less decline than those in the control group who received no cognitive training. Maintaining good health helps us prevent neurological diseases — such as stroke, depression or delirium — that arise when we neglect our well-being.
Furthermore, data shows that cognitive decline is closely associated with anesthesia and surgery in older patients, which is a concern that is becoming increasingly important as our population ages. In the last decade alone, the population of individuals aged 65 years and older in the United States has increased by 34.2%, which accounts for a large number of surgical procedures requiring anesthesia. Because cognitive reserve decreases as we age, the brain is more vulnerable to surgical stresses and anesthesia, raising the risk of neurologic injury such as postoperative neurocognitive disorders (PNDs).
PNDs is an umbrella term that includes both postoperative delirium, which is an acute state of confusion, and postoperative cognitive dysfunction (POCD), which is a longer lasting decline in memory. The conditions were once considered separate, however recent research suggests they are linked, specifically in patients who are at high risk for underlying neurodegenerative diseases or who already have any sort of cognitive impairment. Perioperative stress, vascular disorders and even undiagnosed or preclinical dementia (including mild cognitive impairment) can all contribute to PNDs. About 10% of patients over 65 experience long-term rapid cognitive decline after non-cardiac surgery, highlighting the importance of taking preemptive measures to protect brain health.
Before leaving the patient’s room, the man’s wife turned to us and said, “He may not seem like himself right now, but he’s still in there. I know he’s in there.”
This moment gave me clarity on how important health truly is, and how much it shapes the way we live and how our loved ones remember us. Medicine is not only about treating illness once it arises, but also about promoting good health so patients have the best quality of life. Preventative care and making simple everyday choices are as important to our health as acute interventions. Working alongside Dr. Rahimian showed me that when trouble does strike, though, the epitome of medicine is to see patients at their most vulnerable and work to restore them. I learned to appreciate how much the brain and cognitive health are important for living life as meaningfully as possible. I want to thank Dr. Rahimian for giving me such a selfless view of medicine, and for providing me with an experience that will propel me forward in my future career endeavors.
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