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Sunday, December 8, 2013
Is There An Alternative To Anesthesia?
My husband is 59 years old and has alzheimers. He does not communicate and does not have control of his functions. He has a hernia in his groin and there is talk of a colonoscopy. The only way this could be done is with anesthesia. I am concerned about him being put to sleep as it seems to progress his Alzheimer`s when he was put to sleep for gall bladder surgery in 2003. He is on Namenda and Razydine. He has had alzheimer`s 10 years. Is there an alternative?
Thanks for your question. This is a difficult situation because there is evidence that general anesthesia can have prolonged effects on the brains of elderly people. Around 10-15% or more of elderly patients have not recovered their cognitive function 3 months after anesthesia and surgery. There is a concern also that patients with Alzheimer's disease are particularly susceptible to this effect, however we do not have large scale study data on this yet.
If your husband is completely uncooperative there may be no alternative to deep sedation or general anesthesia. If he is somewhat cooperative however it may be possible to perform the hernia procedure with spinal anesthesia, or even local anesthesia, plus very minimal or even no sedation. Will this protect him from any prolonged brain effects? We don't know for sure as the very limited studies to date have not shown a definite advantage of this approach. If you ask anesthesiologists individually however I think you'll find that most believe that regional anesthesia is less likely to be harmful from this point of view.
The problem is that spinal anesthesia that is adequate for hernia repair does not provide anesthesia to all of the bowel and there might still be a need for additional sedation for the colonoscopy. Local anesthesia is not an option for colonoscopy.
In terms of sedation drugs again there is limited data on the best choices, but avoiding certain drugs like benzodiazepines (valium-type drugs) might be a good idea. The standard sedation/anesthesia drug propofol acts on the same receptors as benzodiazepines so the benefit might be limited however. An alternative is a newer drug that acts on entirely different receptors, called dexmedetomidine (Precedex).
Performing both the hernia operation and the colonoscopy at a single "sitting" would be ideal, but this would have to be arranged with your surgeon and/or gastroenterologist. There might be some concerns on the part of the surgeon about performing a non-sterile procedure after the hernia repair, so the colonoscopy may have to be done first.
You need to discuss all these issues with your anesthesiologist and the other doctors to come to the right decision.
Gareth S Kantor, MD
Assistant Professor of Anesthesiology
School of Medicine
Case Western Reserve University