Confused after Surgery: Post-Operative Cognitive Decline

| November 16, 2012 | 14 Comments

Have you had trouble recovering mentally from surgery and anesthesia?  Do you feel confused?  Learn more from this answer to one guest’s comment.

To Dr. Dave: My daughter had a knee replacement. She lost a lot of blood and was in recovery 3 hrs, due to her blood pressure falling so low. Since then she has healed but she is not herself, no personality, very quiet, not like her at all. Can any of the procedures cause depression or mood change?
Martha
Martha,
I’m sorry to hear about your daughter’s difficult surgical experience. It sounds like you have unfortunately stumbled into an area of ongoing and incomplete anesthesia research: Post Operative Cognitive Dysfunction (POCD).There is a lot of research into the long-term effects of anesthesia, including the effects on the brain.
One problem is that it is quite challenging to design research studies that can tease out what effects are related to anesthesia, and which to the underlying surgical procedure. You don’t get anesthesia unless there is a reason. Without knowing much detail about the specifics in your daughter’s case, here is a list of what MAY be going on:
1. Residual effects of anesthesia, pain medicines. It can take up to several days to completely clear these medicines from the system. A knee replacement is a painful procedure. Depending on whether your daughter had a nerve block or epidural to help relieve the pain, she may be taking a considerable amount of pain medication in the recovery period. Morphine-like medicines can make a person drowsy and contribute to the cognitive symptoms you are describing.
2. Stress of Surgery It is sometimes lost on us that undergoing a major operation, like a knee replacement, can be very tough on the body. The body mounts a “stress response”, where hormone levels and metabolism is altered. These effects can last up to several months as the body slowly recovers.
3. Pre-existing Abnormal Mental Function POCD is more likely in older patients, those with high alcohol intake, a history of mental dysfunction/dementia, and those with a lower IQ (not a complete list). In these patients a decreased “mental reserve” can be unmasked by the combination of surgery and anesthesia. I would add for consideration the possibility of undiagnosed/ unrecognized depression that was present beforehand.
4. Post Traumatic Stress Disorder (PTSD) PTSD is a disorder than can develop when someone experiences or witnesses a traumatic event that he/she perceives as harmful to themselves or a loved one. What’s important is that person’s perception. A major, and potentially painful surgery, can cause PTSD.
While my list of potential causes can not pinpoint what is going on with your daughter, I hope that it begins to give you some idea about what may be going on. The good news is that POCD declines with time (3 months out, for example), especially among young people. But if you think there may be some PTSD or a pre-existing mental issue component present, it would be a good idea to seek professional help.
I pray for your daughter’s speedy and complete recovery. Let me know if there’s any other way we can help.
Sincerely,
Dr. Dave

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Category: Anesthesia Topics, General Anesthesia

Comments (14)

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  1. Jennifer says:

    My husband had spinal surgery in 2006. After his surgery he began showing signs of confusion, paranoia, memory loss and mood swings. He did not have a history of mental illness. Though, when these symptoms began right after surgery the hospital treated him in their psyc unit. This continued for about 3 months. He was in and out of hospitals for psyc treatment. He slowly weened off all the medications and was back to his normal self. It has been about 6 years since this happened. No complications. About 2 weeks ago he went in for another procedure. (Steroid injections in his spine on the nerve endings). They put him completely under for this procedure. He is now again showing the same symptoms as he did in 2006. I am not sure what has brought this on. Doctors here are baffled. We are now going through the motions of psyc treatment again. Is it possible that the anesthesia had anything to do with this? I am very lost and confused with what is happening. Any similar stories would be greatly appreciated.

    • Dr Dave says:

      Jennifer,

      I as so sorry to hear about the difficulties your husband and your family has experienced following his procedures.

      While I mentioned post operative cognitive dysfunction in several places on this site, your husband’s situation seems to be an extreme case. What’s also unusual is that steroid injection procedures are relatively short. So his exposure to anesthesia should have been fairly minimal.

      Without something else playing a role here, it seems very unusual that this would have precipitated the post procedure course you are describing.

      I would encourage you to post your question in our forums here: http://www.anesthesiamyths.com/forum/your-anesthesia-experience-group1/recently-went-under-forum1/

      Perhaps there are some among our readers that have had similar experiences and can share with all of us.

      I wish your husband a full and speedy recovery. I am praying for your family.

      Dr. Dave

  2. Debbie says:

    Dr. Dave,
    About 6 years ago I received a partial hysterectomy that left little pain in my body, but a mental imbalance that left me with sever anxiety, unable to sleep for over a week, could not sit still, if I closed my eyes; dark pictures of blood and what appeared to be pure evil. When I finally began to sleep the anxiety and sadness continued. I felt like I was loosing my mind and was very afraid. I went to my doctor immediately following my discharge from the hospital to ask if something went wrong during the surgery, because of what I knew was not normal and he stated that my surgery had nothing to do with what was going on with me. He prescribe me with some form of anti depressant. I refused to take more medicine, because I thought it was what made me crazy in the first place. So, I trusted in the only thing I knew that could fix me and that was God. After about 6 months of going back and forth to the doctors office, prescribed numerous medicine (did not take), brain scan(on my request), and finally recommending me to a psychiatrist ( did not see). I never gave up praying, but I was getting very discouraged and tired of feeling this way. I was not the same person anymore and it was very scary. One day I told God that I was not afraid anymore and if he wanted me to go through this then I would, because I knew he would take care of me; believe me when I say that I felt the weight of sadness and anxiety lift from me, because I was no longer afraid. I just BELIEVED. Thank you for letting me share my story.

  3. Michelle says:

    Hi Dr. Dave and Dr. Joe, Thanks so much for posting this information, it has been very helpful. I started researching the effects of anesthesia because I am 4 weeks post op on a partial knee replacement and I am having very strange and frustrating processing issues. I am a 42 year old female. I am a college educated preschool teacher. I had a patella femoral knee replacement. With that procedure, I had a femoral block. I had also told the anesthesiologists that I had a “history” (from 1 previous surgery the year before) of post anesthesia nausea/vomiting. I was given an anti-nausea patch and was told that they would take other measures and precautions during surgery to try to avoid that. I did manage to hold off the nausea and vomiting until 24 hours later (12 hours after I removed the patch). I was given Lortab for pain, but I haven’t really taken a lot of them throughout this recovery process. I’m very concerned because I’m noticing not only slow processing, but complete loss of my train of thought. I have been in conversation and completely lost my train of thought and what words come next. It literally leaves me speechless. I can’t even say the next word. Should I be concerned? Is there anything I can do? Thank you so much for your help.

    • Hi Michelle,

      Thanks for trusting us with your question. I am married to a former elementary school teacher, so I know how difficult it is to take care of kiddos when you are having trouble collecting your thoughts.

      Post operative cognitive decline continues to be an ongoing area of research. Everyone responds differently to a general anesthetic and some certainly experience POCD. There is some research into cognitive decline after major orthopedic surgery, which would include total knee replacement.

      I would be concerned if this persists and I would let your primary physician know about it. You might benefit from further testing and treatment. As for what to do in the interim time, I would continue to monitor specific details of your progress and document them. For instance, yesterday I was able to remember this list of five items and today I can remember ten. That way, you can really see if things are improving.

      Let us know when you start to feel more clear.

      • Michelle says:

        Hi Doctor Joe, I apologize for not getting this to you sooner, but I wanted to give an update and hopefully some encouragement to anyone else reading this discussion (which helped me A LOT). I am now five months post op, and I have to say I’m pretty much back to normal (whatever normal is for a 42 year old, lol). I was very concerned in the weeks following my surgery, and wish that I had been prepared for the cognitive side effects. I started to see improvement several weeks after I stopped taking the pain relievers. I think the medications in combination with the anesthesia kept my brain foggy. After all of the chemicals worked out of my system, which probably took a good 2 months in all, I saw a very good improvement. I don’t know whether I had an unusually large dose of anesthesia, or if the combination of anesthesia, nerve block and post op pain medications was just too much, but I know that if I ever have to go through another procedure, that I’ll be better prepared with questions beforehand and prepared for the possible side effects afterwards. I know now that getting off the chemicals as quickly as possible was the best answer for me personally. I hope this helps, and I really appreciate your help and compassion on these discussions.
        Sincerely,
        Michelle

    • Dee says:

      I hope that you are improving. I have been having the same problem that you are. I am now 7 weeks post op. I have been searching for anything that would help my cognitive abilities so that I can get back to work. So far I have not found anything that might help me.

  4. Dee says:

    Doctors, I am having the same difficulties as Michelle, I am now at 7 weeks post op. I have been very afraid and feel better to know that others have had the same problem. I have been searching for any information I can find. I pray that I will be better in another month or so.
    Thank you for this article doctors.

    • David Draghinas says:

      Dee,

      Thanks for reaching out to our community. We all empathize with you and your situation.

      I pray that you continue to show improvement and that you get back to “normal” soon.

      Dr. Dave

      • Michelle says:

        Hi Dee, I just wanted to give an update and hopefully some encouragement….. I am now four months post op, and I have to say I’m pretty much back to normal (whatever normal is for a 42 year old, lol). I was very concerned in the weeks following my surgery, and wish that I had been prepared for the cognitive side effects. I started to see improvement several weeks after I stopped taking the pain relievers. I think the medications in combination with the anesthesia kept my brain foggy. After all of the chemicals worked out of my system, I saw a very good improvement. I hope you are feeling better and back to your normal self soon!

        Michelle

        • Dee says:

          Thank you so much for your reply, I am doing better, I wish I had known about the possibility of cognitive problems. I am also experiencing hair loss which I had hoped I would not experience

      • Dee says:

        Thank you, it has now been 6 months, I have improved though very slowly.

  5. Nancy says:

    Thanks for posting these questions and comments. My 55 year old fiancé is post-op day 4 from bilateral knee replacement surgery, done under general anesthesia per provider preference. He had some difficulties with pain management on day 1, largely due to a malfunctioning IV which no one recognized until I came in. This put him behind and he was loaded up on a heavy cocktail or oral medication, including oral morphine, oxycodone, and Lyrica. He is still hospitalized due to some complications, which I think were largely drug-induced. He is having some confusion, auditory hallucinations, and acts angry with me at times. I don’t know if this is drug/anesthesia-induced and how much sleep deprivation is playing a role. I am getting concerned about his altered behavior.

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