From the Guidelines
Dementia patients undergoing cholecystectomy are at increased risk of postoperative complications, including delirium, longer hospital stays, and increased mortality, and therefore, require careful preoperative assessment, intraoperative management, and postoperative care to minimize these risks. The decision to perform cholecystectomy in dementia patients should involve a careful risk-benefit analysis, considering the potential benefits of surgery against the potential risks, including the impact on cognitive function and quality of life 1.
Preoperative Assessment
Preoperative cognitive assessment is essential to establish a baseline, and careful evaluation of the patient's overall health, including comorbidities and frailty, should be performed to determine the best approach for surgery 1.
Intraoperative Management
During surgery, careful anesthesia management is crucial, often favoring regional anesthesia when possible, and avoiding medications known to worsen confusion 1.
Postoperative Care
Postoperatively, dementia patients benefit from early mobilization, maintaining day-night cycles, ensuring familiar faces nearby, and minimizing unnecessary medications 1. Pain management should be carefully balanced, using acetaminophen as a first-line agent and cautiously using opioids at reduced doses if needed 1. Family involvement throughout the perioperative period helps reduce confusion and anxiety 1.
Alternative Treatments
In some cases, alternative treatments, such as percutaneous cholecystostomy, may be considered for dementia patients who are deemed unfit for surgery, as a bridge to cholecystectomy or as a definitive treatment 1. However, the decision to use alternative treatments should be made on a case-by-case basis, considering the individual patient's needs and circumstances.
Risks and Benefits
Despite the potential risks, cholecystectomy may still be necessary for dementia patients when gallbladder disease causes significant symptoms or complications, and the benefits of surgery outweigh the risks 1. Therefore, a careful and individualized approach is necessary to balance the risks and benefits of cholecystectomy in dementia patients.
From the Research
Risks for Dementia Patients Undergoing Cholecystectomy
- Dementia patients undergoing cholecystectomy may experience similar postoperative outcomes as those without dementia, with comparable complication rates and length of postoperative hospital stay 2.
- However, dementia patients may have a higher rate of delirium development after cholecystectomy 2.
- Another study found that dementia patients who underwent laparoscopic cholecystectomy had a higher incidence of acute cholecystitis, conversion to laparotomy, and non-surgical complications, as well as a longer postoperative hospital stay 3.
- A retrospective analysis of Medicare claims data found that people living with dementia (PLWD) who underwent open or minimally invasive cholecystectomy had a greater risk of intensive interventions and surgical complications, but a lower risk of readmission and mortality compared to those managed medically 4.
- The use of anticholinergic medications, which are commonly used in dementia patients, has been associated with a strong association with all-cause mortality, as well as longer hospital length of stay and other adverse outcomes 5.
- A study on cholecystectomy in the elderly found that older patients, particularly those over 75, are at increased surgical risk due to the presence of co-morbidities and the frequent need for emergency procedures, and that alternative treatments such as percutaneous drainage may be considered 6.
Specific Risks
- Delirium development: dementia patients may be at higher risk of delirium after cholecystectomy 2.
- Acute cholecystitis: dementia patients may have a higher incidence of acute cholecystitis after laparoscopic cholecystectomy 3.
- Conversion to laparotomy: dementia patients may have a higher rate of conversion to laparotomy after laparoscopic cholecystectomy 3.
- Non-surgical complications: dementia patients may have a higher rate of non-surgical complications after laparoscopic cholecystectomy 3.
- Intensive interventions: PLWD who undergo cholecystectomy may have a greater risk of intensive interventions 4.
- Surgical complications: PLWD who undergo cholecystectomy may have a greater risk of surgical complications 4.
- Mortality: the use of anticholinergic medications in dementia patients has been associated with a strong association with all-cause mortality 5.