A word about anesthesias from the LBDA:

When considering any surgery, caregivers should meet with the anesthesiologist in advance. People with LBD often respond to certain anesthetics and surgery with acute confusional states (delirium) and/or may have a precipitous drop in functional abilities which may or may not be permanent. The pros and cons of stopping donepezil, rivastigmine, or galantamine should be carefully considered. If a spinal block or regional block can be used instead of general anesthesia, this would be preferred as those methods are less likely to result in postoperative confusion.

This is so true. Before my husband was diagnosed with LBD, he had a
hip replacement. He came out of it not understanding what people
were saying to him, not being able to read his name in the phone
book and very confused. He spent 2 weeks in Rehab and eventually
most of the sideaffects went away. However, mentally he was never
the same as he was before he went into the operation.

Unfortunately, I can't remember the name of the anesthesia other
than it starts with the letter V.

Fran

Dear Fran,
Yes I am glad this has come out and we now can say for sure, I also think it applies to many people not just LBD.
My Mother who passed away this past April just six months after my Husband, Fractured both her hips the same 2 weeks my husband was near the end, she had to have both hips pinned and she was pretty sharp for someone her age (92) before this happened, I have to say after the surgery she was never the same, she died 4 months later with heart problems.

I agree wholeheartedly with carefully considering alternative methods of anesthesia if possible. My 80 year old father went from a completely independent gentleman living on his own to a competely confused, incontinent and competely dependent resident of a nursing home in the time it took to anesthetize and set his broken hip in September '06.
If we had had any inkling that this could have happened we would have lobbied hard for a spinal block. Since this happened to my Dad, we have heard of a number of other seniors who experienced the same horrible effects. Wouldn't you think the physicians would know that this can happen and give the family and the patient at least the option of discussing alternative anesthesia? This has completely ruined my dear father's life.

Can anyone tell me how quickly the patient became delusional after anethesia? My mother-in-law (with early-moderate LBD) had surgery Thursday and was fine until last night and became delusional and hallucinating. Family members believe it was the Mepergan. However, I'm wondering if it could be a delayed reaction to the anethesia.

Any comments would be appreciated.

I'm not exactly sure how to answer your question - in my father's case, he was delusional right from the moment he came out of surgery. However, we assumed at first it was just the regular effects of anesthesia - then we thought it might be the morphine he was receiving for pain for a few days. The doctors and nurses initially told us that they felt his confusion/hallucinations/delusions would clear up after a few weeks. Apparently it takes an elderly person longer to process the drugs through their liver.
Unfortunately this was not the case for us. It has been 5 long months and although Dad no longer suffers from such severe psychological effects ( he is receiving a tiny amount of the drug Respirdal), we had to place him in a nursing home - he has very little memory at all, is unable to speak in logical sentences, is incontinent and confined to a wheelchair not because his hip didn't heal but because he has lost the ability to understand the mechanics of moving his arms and legs.
So my answer to you would be - it's just a waiting game. Perhaps the negative effects will subside with time, perhaps not. I wish you the best of luck that time will be kind to your loved one.

Dear Woodall,
Here is something off the LBDA site: Written by Jan a volunteer


CONCERNS OF SURGERY

I would like to
preface my comments by saying that the statement you heard, "surgery
is NOT an option for an LBD patient," may be a bit strong. However, I
understand that it is based on the experiences of many LBD caregivers,
which cannot be totally ignored.
It appears we only find caregiver reports of warnings
about the negative impact of surgeries, like this one at
http://brain.hastypastry.net/forums/arc ... 72015.html.
We have not yet found a reliable written source explaining the
specific dangers of surgery to an LBD patient.

Below is a Conclusion (see article at
http://gasnet.med.yale.edu/gta/chapters/parkinsons.php) regarding
patients with Parkinson's showing that guidance for such a well-known
disease is also unclear.

"The anesthetic management of Parkinson's patients is critical to
patient safety and satisfaction. However, it continues to be
controversial as it relies largely on anecdotal reports. The
medication schedule must be ascertained and routes of administration
planned. Patients should be evaluated for respiratory dysfunction
while anticipating cardiovascular and neurological complications.
Lastly propofol should be avoided during stereotactic frame placement
for surgical Parkinson's therapies, with the use of midazolam and/or
diphenhydramine for sedation."

HOWEVER, I found that the warnings of using diphenhydramine (as
mentioned above) is covered in this Editorial Comment at
http://www.parkpub.com/abstracts/abstra ... y02.html#6
"Cognitive impairment and delirium caused by anticholinergic
medications is well recognized. In a prospective observational study
by Agostini et al, the effect of diphenhydramine, a commonly used
over-the-counter antihistamine, was assessed in elderly hospitalized
patients. Diphenhydramine increased the risk of delirious symptoms,
urinary catheterization and length of stay significantly, leading the
investigators to recommend caution when using this drug in the elderly"

Perhaps you can discuss the anesthesia options with the physician, do
some research, and then discuss the possible negative impacts of each
option. At some point most caregivers become more interested in
quality of life over length of life. What becomes difficult is when
our loved one or their doctor wants surgery, for example, and doesn't
understand our concerns because we cannot express them with any
certainty. Even we cannot say for sure that it will have a negative
impact. Doctors are also in a tough spot. They must consider their
medical oath, the wishes of the patient, the patient's family, and
their legal liability. It makes it easier if there is only one
caregiver making these decisions and one who has a good working
relationship with the doctors. But if the doctor has conflicting input
from a spouse, the patient, and/or adult children, then it will be
very difficult for them to base a medical treatment decision on
unsubstantiated reports brought forward by one party.

I hope this helps!

PITTSBURGH, Jan. 25, 2007 – Inhaled anesthetics commonly used in surgery are more likely to cause the aggregation of Alzheimer's disease-related plaques in the brain than intravenous anesthetics say University of Pittsburgh School of Medicine researchers in a journal article published in the Jan. 23 issue of Biochemistry. This is the first report using state-of-the-art nuclear magnetic resonance (NMR) spectroscopic technique to explain the detailed molecular mechanism behind the aggregation of amyloid ? (A?) peptide due to various anesthetics.

http://www.pharmalive.com/News/index.cf ... egoryid=10

The Pharmalive article does say that inhaled anesthestics can be dangerous to those with dementia. The article ALSO said not to use the intravenous anesthetic propofol. Not all intravenous ones are OK, according to the article.

What's interesting about the propofol, though, is that some clinicians specifically recommend it in people with Parkinsonian syndromes. Specifically, someone recommended using Versed (midazolam) to induce anesthesia and Diprivan (propofol) to maintain.

*sigh* Very frustrating. Given that people living with LBD are probably more likely than the general population to need general anesthesia in a given year (orthopaedic injuries come to mind) and are known to tolerate anesthesia exceptionally poorly, it seems like getting some anesthesiologists and neurologists together to come up with a consensus model on anesthetic strategies in LBD/PDD/PD patients would have a dramatic impact on overall outcomes.

Eric

FYI - The Pharmalive article does recommend use of the intravenous anesthetic thiopental.

Actually, I'm not sure what the Pharmalive article says. I don't care for reading articles about press releases or articles about medical journal articles. So, I always go to the source. In this case, the source is a Univ of Pittsburgh press release.

Here's a link to the press release:
http://www.upmc.com/Communications/News ... hetics.htm

And here's the text of it:

Role of Anesthetics in Alzheimer’s Disease: Molecular Details Revealed

PITTSBURGH, January 25, 2007 — Inhaled anesthetics commonly used in surgery are more likely to cause the aggregation of Alzheimer’s disease-related plaques in the brain than intravenous anesthetics say University of Pittsburgh School of Medicine researchers in a journal article published in the Jan. 23 issue of Biochemistry. This is the first report using state-of-the-art nuclear magnetic resonance (NMR) spectroscopic technique to explain the detailed molecular mechanism behind the aggregation of amyloid ß (Aß) peptide due to various anesthetics.

Aß plaques are found in the brains of people with Alzheimer’s disease. Many believe that the uncontrolled clumping of Aß is the cause of Alzheimer’s disease and that the similar aggregation of peptides and proteins play a role in the development of other neurodegenerative diseases such as Parkinson’s disease.

“Many people know of or have heard of an elderly person who went into surgery where they received anesthesia and when they woke up they had noticeable memory loss or cognitive dysfunction,” said Pravat K. Mandal, Ph.D., assistant professor of psychiatry, University of Pittsburgh School of Medicine and lead author of the study. Previous studies by the Pittsburgh researchers found that the inhaled anesthetics halothane and isoflurane and the intravenous anesthetic propofol encouraged the growth and clumping of Aß in a test tube experiment.

“Our prior research had shown in molecular models that anesthetics may play a role by causing amyloid peptides to clump together—something that is thought to signal the advancement of Alzheimer’s disease. In this study, we set out to see why this was happening and to determine if any one form of anesthesia might be a safer option than another,” said Dr. Mandal.

In this study the researchers used NMR spectroscopy to determine how the inhaled anesthetics halothane and isoflurane and the intravenous anesthetics propofol and thiopental interact with Aß influencing the aggregation of Aß in forms commonly found in the brains of people with Alzheimer’s disease. The results were strikingly different between the inhaled and injected anesthetics. The inhaled halothane and isoflurane had the most potent interaction with Aß peptides causing the highest levels of Aß aggregation. The injected anesthetic propofol only interacted and caused aggregation at high concentrations—interaction was not evident at lower concentrations. The intravenous thiopental did not cause the clustering of Aß peptides even at high concentrations. Additionally, the molecular details for the interaction of these anesthetics with Aß peptide were revealed.

Dr. Mandal noted that if the same thing occurs in humans, anesthetics could lead to more amyloid plaques which may lead to earlier memory problems, warranting further studies of anesthetics with Aß both in laboratory and clinical settings.

The study was partly funded through grants from the American Parkinson Disease Association and American Health Assistance Foundation.

I keep hearing orthopaedic and ocular surgeries....what I'm surprised I haven't heard is "heart surgery".

Patients this age have a higher-than-normal number of heart surgeries, but nobody's said "mom had a bypass, and poof, she lost it". There's a pretty well-known phenomenon of diminished cognition from being on heart-lung bypass, but has anyone seen this kind of dramatic decline from cardiac procedures?

Eric