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Making TRACS

May 1, 2013

You know by now, dear readers, that I am generally of the opinion that less is more when it comes to health care.  This is especially true when you get older, when you really should be eating chocolate chip cookies and drinking carbernet, not sitting in doctors offices.  Alas, national trends don’t read my blog before they, um, trend.  This morning I attended a lecture about cardiac surgery in which I was told that the incidence of bypass surgery or valve replacement surgery over the age of 75 has actually been increasing over the last 10 years.  This is partly because non-surgical methods of treating coronary disease have gotten better, but whatever the reason, an older cardiac surgery population presents special challenges.

Over the years after various types of surgery I’ve had patient’s families say to me “You know he just wasn’t the same after his anesthesia”.  Well, no, chances are he wasn’t the same after his SURGERY, in which anesthesia is necessarily involved.  Some really smart people designed a study called TRACS, or Thinking and Recovery After Cardiac Surgery, to try to determine if it’s really true that surgery, specifically cardiac surgery in this case, causes people to be “just not the same” afterwards.

The TRACS people decided to look at patients who get delirious after surgery and those that don’t.  The word “delirious” has come to have many negative, derogatory, and humorous meanings but it’s actually a medical term with specific symptoms.  Delirium, as defined by medical dictionaries is: “a state of mental confusion that develops quickly and usually fluctuates in intensity.”  It is by definition temporary.  People who are delirious have a reduced or inaccurate sense of their environment and this can manifest as delusions, hallucinations, incoherence, memory problems and confusion.  It’s caused by a whole host of things and the elderly are most vulnerable.  About 10% of hospitalized patients will get delirious at some point, and after cardiac surgery that number is more like 50%.  The TRACS guys found that patients are more likely to get delirious after surgery if they are a) older; b) have a history of a stroke; c) have a low albumin level, which means usually that you are not eating well; d) depressed; e) have even mild baseline problems with executive functions like the ability to organize thoughts and activities, prioritize tasks, manage time efficiently, and make decisions.

But remember I said delirium is temporary.  And so it is.  The kicker is that if you get delirious temporarily after cardiac surgery, your length of stay in the hospital is often longer and you are more likely to go to a rehab facility for some length of time before going home.  Additionally, there is a much greater chance that you will have a lasting mild long-term decline in cognitive function.  I’m not saying you turn into a blathering idiot.  Maybe you can’t do the NYT Sunday crossword anymore, or can’t remember all the words to the Gettysburg address.  If you don’t get delirious, you are most likely going to be completely normal by 1 year.  Normal for you anyway.  Remember also that “not the same” can also be a mood disorder like depression or anxiety that has nothing to do with the surgery but everything to do with the fact that you’ve recently faced your own mortality.

Can we doctors prevent delirium, and thus long-term cognitive decline?  Well, we can try, by reducing the number of medications you get, preventing infection, etc.  But if you have the pre-existing problems listed above, there might be nothing we can do.  Does any of this information help you make a decision about whether or not to have cardiac surgery?  It depends on how much you like cabernet.

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