How should psychological issues be assessed and managed in patients undergoing procedures requiring anesthesia?

Assessment and Management of Psychological Issues in Anesthesia Patients

Mental status assessment should be performed routinely during preoperative evaluation and throughout emergence and recovery for all patients undergoing anesthesia, as this detects complications and reduces adverse outcomes. 1

Preoperative Psychological Assessment

Essential Components to Evaluate

Conduct a focused preoperative evaluation that specifically identifies:

• History of psychiatric disorders including depression, anxiety disorders, PTSD, psychosis, and cognitive impairment 1, 2
• Current psychotropic medications with specific attention to dosages, timing, and potential drug interactions with anesthetic agents (particularly medications affecting cytochrome P450 metabolism such as SSRIs, antipsychotics, and benzodiazepines) 1, 2
• Cognitive baseline status using validated tools, particularly in elderly patients where preoperative cognitive impairment increases risk of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) 1
• Risk factors for postoperative cognitive disorders: very old age, frailty, pre-existing cognitive impairment, cerebrovascular disease, and polypharmacy 1
• Substance use history including alcohol, herbal medications (St. John's wort, kava, valerian), and illicit drugs that may alter drug metabolism or potentiate sedation 1

Patient Anxiety and Concerns

Address the four primary patient fears directly during preoperative counseling: 1

• Never waking up from anesthesia
• Dying during surgery
• Awareness during surgery with inability to communicate
• Pain perception during the procedure

Provide written information sheets during pre-anesthesia evaluation, as this reduces preoperative anxiety more effectively than verbal counseling alone. 3 The anesthesiologist's direct reassurance has greater impact than information from nursing staff. 1

Over 50% of patients express concern about awareness under anesthesia, and this anxiety persists postoperatively in 25% of patients even after uneventful anesthetics. 4 Acknowledge these concerns explicitly rather than dismissing them.

Intraoperative Considerations

Mental Status Monitoring

Assess mental status periodically during emergence and recovery using standardized scoring systems. 1 The Observer's Assessment of Alertness/Sedation (OAA/S) scale provides objective measurement of sedation depth. 5

Medication Management

Continue psychotropic medications perioperatively with rare exceptions. 2 Abrupt discontinuation of antidepressants, antipsychotics, or mood stabilizers increases risk of psychiatric decompensation and withdrawal syndromes.

Recognize critical drug interactions: 1, 5, 2

• Benzodiazepines and opioids potentiate respiratory depression when combined with psychotropic medications
• Monoamine oxidase inhibitors (MAOIs) interact dangerously with meperidine and sympathomimetics
• Lithium prolongs neuromuscular blockade
• Antipsychotics lower seizure threshold and may cause QT prolongation

Avoid medications that precipitate delirium in at-risk patients: benzodiazepines, high-dose opioids, antihistamines (including cyclizine), atropine, and corticosteroids. 1

Postoperative Management

Cognitive Monitoring Timeline

Use the following temporal framework for cognitive assessment: 1

• Recovery room through 30 days: Term any cognitive dysfunction as "delayed neurocognitive recovery" rather than postoperative cognitive dysfunction, as most patients recover during this period
• Beyond 30 days: If cognitive symptoms persist past expected surgical recovery, classify as postoperative mild or major neurocognitive disorder (NCD) using DSM-5 criteria (1-2 standard deviations below norms for mild NCD, >2 standard deviations for major NCD)

Delirium Screening and Prevention

Screen for delirium in the recovery room using DSM-IV criteria or short Confusion Assessment Method (CAM), as recovery room delirium strongly predicts postoperative delirium. 1

Implement multimodal delirium prevention: 1

• Optimize pain control using multimodal analgesia (paracetamol first-line, cautious opioid use)
• Maintain normothermia
• Ensure adequate hydration
• Minimize benzodiazepines and anticholinergics
• Facilitate early mobilization and reorientation

PTSD-Specific Considerations

Patients with PTSD have increased risk of emergence delirium. 6 Maintain calm environment during emergence, provide reassurance, and consider having familiar support person present during recovery when feasible.

Special Populations

Elderly Patients

Appoint a consultant anesthesiologist as Lead Clinician for Geriatric Anaesthesia to champion dignity and quality of care for older patients. 1 This addresses the systemic disregard for elderly patient dignity documented in multiple reports.

Assess frailty and functional status preoperatively, as these predict postoperative cognitive complications better than chronological age alone. 1

Pediatric Patients

Recognize that simple preoperative anxiolysis differs fundamentally from deep procedural sedation requirements. 1 Tailor psychological preparation to developmental stage, using age-appropriate language and involving parents/caregivers.

For children, the presence of a partner or friend during recovery alleviates anxiety more effectively than any other intervention. 1

Documentation Requirements

Document the following in the medical record: 1

• Baseline mental status assessment
• Specific psychiatric diagnoses and medications
• Patient's cognitive concerns (required for NCD diagnosis per DSM-5)
• Serial mental status assessments during emergence and recovery
• Any deviations from expected cognitive recovery