General anesthesia and dementia patients?

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General anesthesia and dementia patients?

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87 year old M-I-L with dementia living in AL. Tests have shown that she has severe hydronephrosis (urine can not drain out due to a blockage or obstruction) of the left kidney. Her right kidney is fine. Ultrasound and XRAYS do not show stones just calcifications. A cat scan has been ordered to try and get a better look.

She is not in any discomfort; other than getting frequent UTIs which are treated with antibiotics. No other symptoms.

We are told by the urologist that she would not be a candidate for shock wave therapy. Depending on what they find surgery under general anesthesia to remove an obstruction may be recommended.

I would really appreciate opinions and shared experiences of those of you that have been through surgery with general anesthesia for a LO.

We are torn as to what would be in her best interests. My fear is that the anesthesia will worsen her dementia and that she will not be able to return to AL but have to go into a nursing home.

Thank you

Alzheimer's & Dementia Care Decisions Medical Care

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All the posts on this site suggest that surgery with anaesthesia is likely to be very disruptive and could worsen dementia. Perhaps the best thing would be to get as much detail as you can about discomfort and deterioration, if you don’t go down the surgery path. Is discomfort likely to occur, when, how bad and would any pain be treatable? Is her health likely to worsen? Again, when and how would it work out? Then perhaps you could give her the options. If she is still in AL, perhaps her dementia is not so bad that she can’t make a sensible choice herself. If she decides that she would prefer to avoid surgery and its risks, it will stop you feeling that you are responsible for whatever goes wrong. Best wishes.

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I would make sure the doctor fully understands and appreciates why you are concerned about general anesthesia. You would be surprised how many seem clueless. I don't think they teach much about dementia in medical school. AND, it's also the aftercare. What would be involved? What kind of incision? Dementia patients are often not able to comply with post surgery precautions like, not lifting, bending, pulling, or yanking out stitches. Depending on her level of progression, it could require around the clock constant monitoring until fully healed and maybe hand restraints. So, I'd ask a lot of questions. It's a tough decision.

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After care is definitely a concern. Mom developed cellulitis just before the move to MC, which delayed the move a few days during treatment. My brother had come up for the move, so he was the one cleaning and changing bandages. He reported that just after finishing, she ripped the bandaging off and declared she needed a new one! She wasn't even that bad with dementia at that point (bad enough that she would be better in MC rather than living alone as she could not cook anymore or take care of finances and herself - the fact that she never dealt with the infection OR bothered to tell one of us was telling!)
Anesthesia in the elderly with dementia can be very detrimental, but it can also after elders who did not have dementia (might seem to have it after surgery, just like sometimes UTIs can do and some never return to pre-surgery levels.)

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Surgery itself is a RISK, but so is doing nothing. If she is in assisted living and not a nursing home, chances are you can simply ask her what she wants to do. Decisions must be made with completely understanding of risks and benefits, which I do not believe was explained to you. ASK the urologist of what will happen IF surgery is not done. If the doctor did not explain that, in my opinion you need a new doctor. When it comes to surgery you can always get a second opinion..but I would stay away from a doctor who did not explain risks and benefits completely.

Current guidelines with regards to patients with cognitive decline and anesthesia
published January 2019
https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14530

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Her doctors will need to fix this sooner rather than later as hydronephrosis will kill the remaining healthy kidney tissue when the urine backs up and is not excreted.

I am not necessarily sure drinking more water will help- this will cause more back up of urine into the kidneys. If she is in the hospital she is probably receiving IV fluids for hydration. This too is excreted by the kidneys.

My guess is her doctors will insert a suprapubic catheter to bypass the blockage if she isn’t a good surgical candidate.

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As mentioned, previously, read On Being Mortal by Atul Gawande. 15 years into a dementia journey with my mom, and 4 years of not being able to verbally express herself, I would tell you don't do the surgery. Not just because of the risks of anesthesia, surgery, and inability to follow pre and post-op instructions, but as my mom concluded, most other ways to die would be preferable. Actually she said any other way. 10 years ago, 6 months after we convinced her to seek medical help and she got her diagnosis of probable Alzheimer, she had abdominal pain. I wanted her to pursue testing, but she said she would rather die of cancer. I explained it could be something else that is correctable ( which she reminded me I had said about the dementia symptoms). She refused treatment, the abdominal pain eventually went away. Here we are, she is in a LTC facility, with only several people who visit her, even though I explain to them she is aware most times of their presence. 90% of the time she gives me a smile of recognition, she cheers up when I take her for a walk or if she sees children. It breaks my heart to know she is captured in a body and that the world is often confusing, frustrating, and depressing; but she is still feeling the emotions of her perception of the world. I am now a believer of AND (allow natural death). I now understand what she was saying 10 years ago. I would get palliative care for her, and then hospice when the time comes. Read the book. Also people have said to me most of the time, she doesn't have any clue of her situation. As she always responds to me in some way, as little as just opening her mouth when I touch her lip with spoon, to a kiss, to occasionally getting out appropriate words "your hands are cold".

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My husband had an obstruction with a swollen kidney and the interventional radiologist performed the procedure under sedation not general anesthesia. It was outpatient. They could not remove the obstruction and left a drainage tube leading from the kidney to the outside and this drained the urine into a collection bag. I had to flush the tubing daily. He had the procedure repeated later and they still couldn’t remove it. A swollen and obstructed kidney can cause death so it’s nothing you ignore. I don’t know why they couldn’t do this procedure on her without a general using sedation like what is used with a colonoscopy.
At 96 yo my father had his appendix removed and yes the anesthesia affected him. But what can you do? He was a bit more forgetful and all afterwards. He also had a general when he broke his femur at the age of 97! Lordy!!

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I agree with Sunnygirl. I am a nurse and have taken on the task of managing inlaws care; they are in IL because for now, FIL is still able manage some things. But he has really neglected a lot of conditions and so we have been going to the doctor together a lot. He sees geriatrician, nephrologist, dermatologist (for skin cancer he ignored for 20 years), eye surgeon, macular degeneration specialist and a cardiologist. And except for the geriatrician, most of these doctors are clueless about the overall condition. My FIL, who has mild vascular dementia (worsening rapidly) still seems very intact when they ask him questions. I am now always in the room and really he answers questions very firmly, if not always accurately. I usually tell someone on the way in that he has dementia and won't remember any details or recommendations and I have had to guide doctors, especially the dermatologist who got really excited to see this really large skin cancer, when the treatment recommendations got too crazy.
Just because a procedure CAN be done does not mean it SHOULD be done. And that leaves family members with the difficult and painful duty of making life or death decisions for their LO's.

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Some surgeons are just too keen on surgery, without considering the whole patient! As noted, even other doctors might not consider the consequences of their recommendations. There are those who get it though. I recently took mom to orthopedics for severe leg pain (she was refusing to walk, stand and sometimes wouldn't eat, which is not her norm.) Long ago she used to say she needed to get her knees 'done', but never followed through. Now, at age 95 with dementia, I do not consider it an option, but allowing her to exist like that WITH all that pain, no. They did xrays (compared to ones taken about a year ago.) When he came to talk to us, he said if she were 20 years younger, he would recommend surgery, the knees were that bad! Clearly he knew it was not going to be an option (and I was not going to ask for it either!) I asked if he could do an injection in the more painful knee, hoping it might prevent some pain for the time being (might need to repeat later, generally those are only good for a few months.) So far, so good....
Now I just need to get mom a new GP. The one we have doesn't take anything we bring her in for very seriously... It is in the works!

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My mom in early stages of Alzheimer's was diagnosed with uterine cancer, had the hysterectomy under general anesthesia, and chemo. This was the beginning of a much more rapid decline.

Hindsight being 20/20 she probably should not have had the surgery. She lived another, long ten years with worsening dementia. Cancer is sometimes very slow progressing in the elderly. Think and carefully consider her options here. Assisted living may very well not be appropriate following the surgery for many different reasons.

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My husband is 80 years old with vascular dementia. Last year he had surgery for an inguinal hernia, with the same concern about general anesthesia. The surgeon recommended the anesthesiologist do a nerve block instead, which worked well with no issues. You might want to ask her surgeon about this possibility. Best thoughts!

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I am (80) with no dementia and my wife is (80) with Alzheimer’s. We have both had to have surgery within the past two years under a general anesthesia.
I meet with the anesthesiologist way in advance and ask them to use Desfurane rather than Isoflurane in the anesthesia cocktail. I had researched that issue before. Maybe it is just the power of suggestion for me but neither of us has suffered any additional issues.

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Thank you! There is a wealth of information on this site. So helpful!

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