This episode is a conversation with Dr. Catherine Price about perioperative cognitive decline (including delirium), particularly in older adults. Various topics are covered, including the frequency of cognitive problems post-surgery, predisposing and precipitating factors for post-surgical cognitive impairments, surgery as a biological stress test for the brain, the mechanisms by which non-CNS surgery can impact cognitive functioning, depth of anesthesia and brain health, the impact of pre-operative cognitive functioning on healthcare decision making before, during, and after surgery, the role of neuropsychology in care for surgical patients, and interventions for perioperative cognitive problems.
About Cate
Dr. Catherine (Cate) Price is an Associate Professor and Board-Certified Neuropsychologist in the Department of Clinical and Health Psychology, and the Department of Anesthesiology, at the University of Florida. She is an elected Fellow within the American Psychological Association, and the 2021 International Neuropsychological Society Arthur Benton Mid-Career Awardee for her contribution to the field of neuropsychology in the area of perioperative cognitive medicine. She is also the elected Chair of the 2025-2027 Perioperative Cognitive and Delirium Professional Interest Group of the Alzheimer’s Association International Society to Advance Alzheimer’s Research and Treatment (ISTAART), and Chair of the APA Division 40 Fellow Committee. Dr. Price received advanced graduate training via Drexel University, the University of Pennsylvania, and the University of Florida. She is an expert in dementia, movement disorders, and perioperative cognitive disorders, and neuroimaging methods. She is an independent NIH investigator studying neuroimaging and neuropsychology predictors of cognitive decline for older adults with and without neurodegenerative disorders electing surgeries with anesthesia. She currently holds an NIH leadership grant to develop the Perioperative Cognitive Anesthesia Network (PeCAN) at the University of Florida in order to improve evidence-based medical care for older adults with neurodegenerative disorders electing surgery with anesthesia. Her professional goal is to advance the perioperative care for older adults with neurodegenerative risk factors electing surgery. She is an advocate of preventative medicine and establishing routine preoperative cognitive screening and delirium assessments within hospital settings.
References
Alonso, C. H., Tanner, J. J., Wiggins, M. E., Sinha, P., Parvataneni, H. K., Ding, M., Seubert, C. N., Rice, M. J., Garvan, C. W., & Price, C. C. (2019). Proof of principle: Preoperative cognitive reserve and brain integrity predicts intra-individual variability in processed EEG (Bispectral Index Monitor) during general anesthesia. PloS One, 14(5), e0216209. https://doi.org/10.1371/journal.pone.0216209
Arias, F., Riverso, M., Levy, S. A., Armstrong, R., Estores, D. S., Tighe, P., & Price, C. C. (2019). Pilot Study: Neurocognitive Disorders and Colonoscopy in Older Adults. Anesthesia and Analgesia/Anesthesia & Analgesia, 129(3), e89–e93. https://doi.org/10.1213/ane.0000000000004212
Arias, F., Wiggins, M., Urman, R. D., Armstrong, R., Pfeifer, K., Bader, A. M., Libon, D. J., Chopra, A., & Price, C. C. (2020). Rapid in-person cognitive screening in the preoperative setting: Test considerations and recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI). Perioperative Care and Operating Room Management, 19, 100089. https://doi.org/10.1016/j.pcorm.2020.100089
Bandyopadhyay, S., Wittmayer, J., Libon, D. J., Tighe, P., Price, C., & Rashidi, P. (2023). Explainable semi-supervised deep learning shows that dementia is associated with small, avocado-shaped clocks with irregularly placed hands. Scientific Reports, 13(1). https://doi.org/10.1038/s41598-023-34518-9
Benoit, A. G., Campbell, B. I., Tanner, J. R., Staley, J. D., Wallbridge, H. R., Biehl, D. R., Bradley, B. D., Louridas, G., Guzman, R. P., & Fromm, R. A. (2005). Risk factors and prevalence of perioperative cognitive dysfunction in abdominal aneurysm patients. Journal of Vascular Surgery, 42(5), 884–890. https://doi.org/10.1016/j.jvs.2005.07.032
Berger, M., Schenning, K. J., Brown, C. H., Deiner, S. G., Whittington, R. A., & Eckenhoff, R. G. (2018). Best Practices for Postoperative Brain Health: Recommendations From the Fifth International Perioperative Neurotoxicity Working Group. Anesthesia and Analgesia/Anesthesia & Analgesia, 127(6), 1406–1413. https://doi.org/10.1213/ane.0000000000003841
Berger, M., Ryu, D., Reese, M., McGuigan, S., Evered, L. A., Price, C. C., Scott, D. A., Westover, M. B., Eckenhoff, R., Bonanni, L., Sweeney, A., & Babiloni, C. (2023). A Real-Time Neurophysiologic Stress Test for the Aging Brain: Novel Perioperative and ICU Applications of EEG in Older Surgical Patients. Neurotherapeutics, 20(4), 975–1000. https://doi.org/10.1007/s13311-023-01401-4
Borozdina, A., Qeva, E., Cinicola, M., & Bilotta, F. (2018). Perioperative cognitive evaluation. Current Opinion in Anesthesiology, With Evaluated MEDLINE/Current Opinion in Anaesthesiology, 31(6), 756–761. https://doi.org/10.1097/aco.0000000000000658
Brown, C., & Deiner, S. (2016). Perioperative cognitive protection. British Journal of Anaesthesia, 117, iii52–iii61. https://doi.org/10.1093/bja/aew361
Daiello, L. A., Racine, A. M., Gou, R. Y., Marcantonio, E. R., Xie, Z., Kunze, L. J., Vlassakov, K. V., Inouye, S. K., & Jones, R. N. (2019). Postoperative Delirium and Postoperative Cognitive Dysfunction. Anesthesiology, 131(3), 477–491. https://doi.org/10.1097/aln.0000000000002729
Davoudi, A., Sajdeya, R., Ison, R., Hagen, J., Rashidi, P., Price, C. C., & Tighe, P. J. (2023). Fairness in the prediction of acute postoperative pain using machine learning models. Frontiers in Digital Health, 4. https://doi.org/10.3389/fdgth.2022.970281
Dion, C., Tanner, J. J., Formanski, E. M., Davoudi, A., Rodriguez, K., Wiggins, M. E., Amin, M., Penney, D., Davis, R., Heilman, K. M., Garvan, C., Libon, D. J., & Price, C. C. (2022). The functional connectivity and neuropsychology underlying mental planning operations: data from the digital clock drawing test. Frontiers in Aging Neuroscience, 14. https://doi.org/10.3389/fnagi.2022.868500
Emrani, S., Lamar, M., Price, C. C., Wasserman, V., Matusz, E., Au, R., Swenson, R., Nagele, R., Heilman, K. M., & Libon, D. J. (2020). Alzheimer’s/Vascular Spectrum Dementia: Classification in Addition to Diagnosis. Journal of Alzheimer’s Disease, 73(1), 63–71. https://doi.org/10.3233/jad-190654
Giovannetti, T., Price, C. C., Fanning, M., Messé, S., Ratcliffe, S. J., Lyon, A., Kasner, S. E., Seidel, G., Bavaria, J. E., Szeto, W. Y., Hargrove, W. C., Acker, M. A., & Floyd, T. F. (2019). Cognition and Cerebral Infarction in Older Adults After Surgical Aortic Valve Replacement. The Annals of Thoracic Surgery, 107(3), 787–794. https://doi.org/10.1016/j.athoracsur.2018.09.057
Hamlet, K. M., Pasternak, E., Rabai, F., Mufti, M., Alonso, C. H., & Price, C. C. (2021). Perioperative Multidisciplinary Delirium Prevention: A Longitudinal Case Report. A&a Practice, 15(1), e01364. https://doi.org/10.1213/xaa.0000000000001364
Hardcastle, C., Huang, H., Crowley, S., Tanner, J., Hernaiz, C., Rice, M., Parvataneni, H., Ding, M., & Price, C. C. (2019). Mild Cognitive Impairment and Decline in Resting State Functional Connectivity after Total Knee Arthroplasty with General Anesthesia. Journal of Alzheimer’s Disease, 69(4), 1003–1018. https://doi.org/10.3233/jad-180932
Huang, H., Tanner, J., Parvataneni, H., Rice, M., Horgas, A., Ding, M., & Price, C. (2018). Impact of Total Knee Arthroplasty with General Anesthesia on Brain Networks: Cognitive Efficiency and Ventricular Volume Predict Functional Connectivity Decline in Older Adults. Journal of Alzheimer’s Disease, 62(1), 319–333. https://doi.org/10.3233/jad-170496
Humeidan, M. L., Otey, A., Zuleta-Alarcon, A., Mavarez-Martinez, A., Stoicea, N., & Bergese, S. (2015). Perioperative Cognitive Protection-Cognitive Exercise and Cognitive Reserve (The Neurobics Trial): A Single-blind Randomized Trial. Clinical therapeutics, 37(12), 2641–2650. https://doi.org/10.1016/j.clinthera.2015.10.013
Humeidan, M. L., Reyes, J. P. C., Mavarez-Martinez, A., Roeth, C., Nguyen, C. M., Sheridan, E., Zuleta-Alarcon, A., Otey, A., Abdel-Rasoul, M., & Bergese, S. D. (2021). Effect of Cognitive Prehabilitation on the Incidence of Postoperative Delirium Among Older Adults Undergoing Major Noncardiac Surgery. JAMA Surgery, 156(2), 148. https://doi.org/10.1001/jamasurg.2020.4371
Jildenstål, P. K., Rawal, N., Hallén, J. L., Berggren, L., & Jakobsson, J. G. (2014). Perioperative management in order to minimise postoperative delirium and postoperative cognitive dysfunction: Results from a Swedish web-based survey. Annals of Medicine and Surgery, 3(3), 100–107. https://doi.org/10.1016/j.amsu.2014.07.001
Jones, L. C., Dion, C., Efron, P. A., & Price, C. C. (2021). Sepsis and Cognitive Assessment. Journal of Clinical Medicine, 10(18), 4269. https://doi.org/10.3390/jcm10184269
Karunarathna, I., Kusumarathna, K., Gunarathna, I., Jayathilaka, P., Senarathna, R., Wijayawardana, K., . . . Walgama, K. (2024). Ketamine: Mechanisms, Applications, and Future Directions. Uva Clinical
Kong, H., Xu, L., & Wang, D. (2022). Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neuroscience & Therapeutics, 28(8), 1147–1167. https://doi.org/10.1111/cns.13873
Kotekar, N., Shenkar, A., & Nagaraj, R. (2018). Postoperative cognitive dysfunction – current preventive strategies. Clinical Interventions in Aging, Volume 13, 2267–2273. https://doi.org/10.2147/cia.s133896
Libon, D. J., Matusz, E. F., Cosentino, S., Price, C. C., Swenson, R., Vermeulen, M., Ginsberg, T. B., Okoli-Umeweni, A. O., Powell, L., Nagele, R., Tobyne, S., Gomes-Osman, J. R., & Pascual-Leone, A. (2023). Using digital assessment technology to detect neuropsychological problems in primary care settings. Frontiers in Psychology, 14. https://doi.org/10.3389/fpsyg.2023.1280593
Mahanna-Gabrielli, E., Schenning, K. J., Eriksson, L. I., Browndyke, J. N., Wright, C. B., Evered, L., Scott, D. A., Wang, N. Y., Brown, C. H., Oh, E., Purdon, P., Inouye, S., Berger, M., Whittington, R. A., & Deiner, S. (2019). State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018. British Journal of Anaesthesia, 123(4), 464–478. https://doi.org/10.1016/j.bja.2019.07.004
Matusz, E. F., Price, C. C., Lamar, M., Swenson, R., Au, R., Emrani, S., Wasserman, V., Libon, D. J., & Thompson, L. I. (2022). Dissociating Statistically Determined Normal Cognitive Abilities and Mild Cognitive Impairment Subtypes with DCTclock. Journal of the International Neuropsychological Society, 29(2), 148–158. https://doi.org/10.1017/s1355617722000091
Mohamed, B., Ramachandran, R., Rabai, F., Price, C. C., Polifka, A., Hoh, D., & Seubert, C. N. (2021). Frailty Assessment and Prehabilitation Before Complex Spine Surgery in Patients With Degenerative Spine Disease: A Narrative Review. Journal of Neurosurgical Anesthesiology, 35(1), 19–30. https://doi.org/10.1097/ana.0000000000000787
Monk, T. G., & Price, C. C. (2011). Postoperative cognitive disorders. Current Opinion in Critical Care, With Evaluated MEDLINE/Current Opinion in Critical Care, 17(4), 376–381. https://doi.org/10.1097/mcc.0b013e328348bece
Nadelson, Sanders, R., & Avidan. (2014). Perioperative cognitive trajectory in adults. British Journal of Anaesthesia, 112(3), 440–451. https://doi.org/10.1093/bja/aet420
O’Gara, B. P., Mueller, A., Gasangwa, D. V. I., Patxot, M., Shaefi, S., Khabbaz, K., Banner-Goodspeed, V., Pascal-Leone, A., Marcantonio, E. R., & Subramaniam, B. (2020). Prevention of Early Postoperative Decline: A Randomized, Controlled Feasibility Trial of Perioperative Cognitive Training. Anesthesia and Analgesia/Anesthesia & Analgesia, 130(3), 586–595. https://doi.org/10.1213/ane.0000000000004469
O’Gara, B. P., Gao, L., Marcantonio, E. R., & Subramaniam, B. (2021). Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology, 135(6), 1132–1152. https://doi.org/10.1097/aln.0000000000004046
Peden, C. J., Miller, T. R., Deiner, S. G., Eckenhoff, R. G., Fleisher, L. A., Fleisher, L., Deiner, S., Eckenhoff, R., Peden, C., Brown, I., Charles, H., Culley, D., Eriksson, L. I., Evered, L., Gelb, A., Grocott, M., Hemmings, H., Hughes, C., Leung, J., . . . Whittington, R. A. (2021). Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team. British Journal of Anaesthesia, 126(2), 423–432. https://doi.org/10.1016/j.bja.2020.10.037
Polcz, V. E., Barrios, E. L., Chapin, B., Price, C. C., Nagpal, R., Chakrabarty, P., Casadesus, G., Foster, T., Moldawer, L. L., & Efron, P. A. (2023). Sex, sepsis and the brain: defining the role of sexual dimorphism on neurocognitive outcomes after infection. Clinical Science, 137(12), 963–978. https://doi.org/10.1042/cs20220555
Price, C. C. (2022). The New Frontier of Perioperative Cognitive Medicine for Alzheimer’s Disease and Related Dementias. Neurotherapeutics, 19(1), 132–142. https://doi.org/10.1007/s13311-021-01180-w
Price, C. C., Tanner, J. J., Schmalfuss, I., Garvan, C. W., Gearen, P., Dickey, D., Heilman, K., McDonagh, D. L., Libon, D. J., Leonard, C., Bowers, D., & Monk, T. G. (2014). A Pilot Study Evaluating Presurgery Neuroanatomical Biomarkers for Postoperative Cognitive Decline after Total Knee Arthroplasty in Older Adults. Anesthesiology, 120(3), 601–613. https://doi.org/10.1097/aln.0000000000000080
Price, C. C., Levy, S. A., Tanner, J., Garvan, C., Ward, J., Akbar, F., Bowers, D., Rice, M., & Okun, M. (2015). Orthopedic Surgery and Post-Operative Cognitive Decline in Idiopathic Parkinson’s Disease: Considerations from a Pilot Study. Journal of Parkinson’s Disease/Journal of Parkinson’s Disease (Online), 5(4), 893–905. https://doi.org/10.3233/jpd-150632
Rawal, G., Yadav, S., & Kumar, R. (2017). Post-intensive care syndrome: An overview. Journal of Translational Internal Medicine, 5(2), 90–92. https://doi.org/10.1515/jtim-2016-0016
Rengel, K. F., Pandharipande, P. P., & Hughes, C. G. (2018). Postoperative delirium. La Presse Médicale, 47(4), e53–e64. https://doi.org/10.1016/j.lpm.2018.03.012
Rodriguez, K., Fugard, M., Amini, S., Smith, G., Marasco, D., Shatzer, J., Guerrero, M., Garvan, C., Davis, J., & Price, C. (2021). Caregiver Response to an Online Dementia and Caregiver Wellness Education Platform. Journal of Alzheimer’s Disease Reports, 5(1), 433–442. https://doi.org/10.3233/adr-200292
Schulman‐Green, D., Hshieh, T., Adamis, D., Avidan, M. S., Blazer, D. G., Fick, D. M., Oh, E., Morandi, A., Price, C., Verghese, J., Schmitt, E. M., Jones, R. N., & Inouye, S. K. (2021). Domains of delirium severity in Alzheimer’s disease and related dementias. Journal of the American Geriatrics Society, 70(5), 1495–1503. https://doi.org/10.1111/jgs.17624
Simone, S. M., Price, C. C., Floyd, T. F., Fanning, M., Messé, S. R., Drabick, D. a. G., & Giovannetti, T. (2022). Preoperative cognition predicts clinical stroke/TIA and mortality after surgical aortic valve replacement in older adults. Neuropsychology, Development, and Cognition. Section a, Journal of Clinical and Experimental Neuropsychology/Journal of Clinical and Experimental Neuropsychology, 44(8), 550–561. https://doi.org/10.1080/13803395.2022.2142526
Tanner, J. J., Amin, M., Hardcastle, C., Parvataneni, H., Vaillancourt, D. E., Mareci, T. H., & Price, C. C. (2019). Better Brain and Cognition Prior to Surgery Is Associated With Elevated Postoperative Brain Extracellular Free-Water in Older Adults. Frontiers in Aging Neuroscience, 11. https://doi.org/10.3389/fnagi.2019.00117
Taylor, G. B., Radhakrishnan, N., Fisher, C. L., Price, C., Tighe, P., Le, T., & Bylund, C. L. (2021). A qualitative analysis of clinicians’ communication strategies with family members of patients experiencing hospital-acquired delirium. Geriatric Nursing, 42(3), 694–699. https://doi.org/10.1016/j.gerinurse.2021.02.009
Terrando, N., Brzezinski, M., Degos, V., Eriksson, L. I., Kramer, J. H., Leung, J. M., Miller, B. L., Seeley, W. W., Vacas, S., Weiner, M. W., Yaffe, K., Young, W. L., Xie, Z., & Maze, M. (2011). Perioperative Cognitive Decline in the Aging Population. Mayo Clinic Proceedings, 86(9), 885–893. https://doi.org/10.4065/mcp.2011.0332
Terry, E. L., Tanner, J. J., Cardoso, J. S., Sibille, K. T., Lai, S., Deshpande, H., Deutsch, G., Goodin, B. R., Bradley, L. A., Price, C. C., & Fillingim, R. B. (2020). Associations of pain catastrophizing with pain-related brain structure in individuals with or at risk for knee osteoarthritis: Sociodemographic considerations. Brain Imaging and Behavior,15(4), 1769–1777. https://doi.org/10.1007/s11682-020-00372-w
Vacas, S., Degos, V., Feng, X., & Maze, M. (2013). The neuroinflammatory response of postoperative cognitive decline. British Medical Bulletin, 106(1), 161–178. https://doi.org/10.1093/bmb/ldt006
Wiggins, M., Arias, F., Urman, R. D., Richman, D. C., Sweitzer, B. J., Edwards, A. F., Armstrong, M. J., Chopra, A., Libon, D. J., & Price, C. (2020). Common neurodegenerative disorders in the perioperative setting: Recommendations for screening from the Society for Perioperative Assessment and Quality Improvement (SPAQI). Perioperative Care and Operating Room Management, 20, 100092. https://doi.org/10.1016/j.pcorm.2020.100092
Zhao, L., Zhu, H., Mao, W., Zhou, X., Xie, Y., & Li, L. (2023). Effects of perioperative cognitive function training on postoperative cognitive dysfunction and postoperative delirium: a systematic review and meta-analysis. Frontiers in Neurology, 14. https://doi.org/10.3389/fneur.2023.1146164
