San Antonio Express News

 Richard A. Marini, Staff Writer Sep 19, 2025

Star Bradbury said her late stepfather, William Hyde, was a “sweet, wonderful man.” But two decades ago, when he woke from colon cancer surgery, he turned shockingly violent.

“He was convinced he was being kidnapped by the Nazis in World War II,” said Bradbury, an aging life care expert and author of “Successfully Navigating Your Parents’ Senior Years.” “He was so agitated, the hospital staff had to tie him down. It was horrible.”

Today, Bradbury suspects her elderly stepfather’s out-of-character actions may have been caused by the anesthesia he received prior to surgery. She also recalls that — although he was never formally diagnosed with dementia — he’d previously been showing signs of physical and mental decline, potential risk factors for what has since become known as postoperative cognitive dysfunction, or POCD. For most patients, a successful surgery means the physical ailment is fixed. But for thousands of others, especially older adults, a different kind of recovery struggle, quiet and bewildering, begins in the days and weeks following surgery.

Relatively unknown, even in the medical community, POCD can manifest in a number of ways: memory problems, delirium, difficulty focusing, a reduced ability to think clearly, agitation, violence and more. These often-misunderstood consequences can profoundly affect a person’s quality of life, independence and social connections.

The sad news for Hyde and his family is that, by utilizing screening procedures increasingly — albeit not universally — available today, his doctors may have been able to predict that he’d react poorly to the anesthesia and could have taken steps to minimize his risk of POCD.

“Thankfully this is something that, in the past couple of years, people have been doing a lot more research about,” said Dr. Odmara Barreto Chang, associate professor of anesthesiology at the University of California San Francisco and a member of the American Society of Anesthesiologists Committee on Geriatric Anesthesia. “We now have strong evidence, for example, that if you have even mild cognitive impairment, you’re at increased risk for postoperative delirium and long-term cognitive decline.”

Patients have long been screened for health problems before surgery to help doctors identify potential complications. This can include everything from taking a simple medical history to a doing a complete cardiac scan. Such tests allow surgeons and anesthesiologists to take precautions to ensure the best possible outcome.

The one organ that’s typically not screened, however, is the brain. Yet the older the patient, the more important such screening becomes, because surgery can be hard on the brain. “Age plays a big role in brain health when it comes to surgical outcome — how well a patient recovers,” said Catherine Price, a professor of clinical and health psychology in the University of Florida’s College of Public Health and Health Professions. “Old brains don’t bounce back as quickly and easily as young ones do.”

Price, who is also a member of UF’s McKnight Brain Institute, has been studying POCD for 25 years and is the founder and director of the university’s Perioperative Cognitive Anesthesia Network, or PeCAN, which has helped develop screening procedures to identify adults who are most at risk of developing cognitive problems following surgery.

It’s not at all unusual for older patients to become cognitively impaired following surgery or to wake up “loopy,” as one surgeon put it.

Bradbury, who has worked in senior living settings for 20 years, said she’s witnessed plenty of elderly patients who are not themselves after having surgery. “Some never regain their cognitive functioning at the level they had before,” she said.

Post-surgical psychosis can take many guises. Like Hyde, patients can become delirious and confused. They can be agitated, aggressive, even combative. They may even yell at hospital staff, pull at their vent tubes and IV lines and refuse to follow orders. Others will remain overly sedated, inattentive and difficult to wake completely.

Still others may appear sharp and oriented, but have difficulty with memory, thinking or making decisions.

After Daniel Cole’s 85-year-old father had a coronary bypass, he fell into what Cole described as a sustained brain fog.

“Even though he had a good quality of life for several years before he died, he never fully recovered,” said Cole, a neuroanesthesiologist, and president of Anesthesia Patient Safety Foundation. “He was never quite as sharp as he was before the surgery.”

Price recalled a patient who suddenly had difficulty playing bridge, a pastime they’d previously enjoyed. Another was unable to return to work following knee surgery because they could no longer function in an office environment.

For these reasons, protecting brain health should be a standard part of safe surgery, according to Cole, especially for older adults at higher risk.

“It’s much more than a medical issue,” he said. “It’s really about the patient’s dignity, identity, and quality of life.”

While researchers don’t know exactly what causes POCD, they’ve identified a number of risk factors. These include age, frailty, depression, and illnesses such as diabetes and high blood pressure (especially when poorly treated), and dementia, whether apparent or not.

Price’s PeCAN clinic works with patients prior to surgery, screening them with a test that takes only a few minutes and is recommended by the American College of Surgeons. There are a number of different tests available, but the one PeCAN often uses is the “clock test.” “They’re given a blank sheet of paper asked to draw a clock: the outline, the numerals and the hands set to a specific time,” Price said. “Everything has to be in the right place.” Red flags can include everything from oddly-shaped clock faces, numerals bunched to one side and failure to properly place the “anchor” numerals — 3, 6, 9 and 12. Next they’re shown a picture of a clock and asked to replicate it on a second blank sheet. “Looking at how they improve from the first drawing to the second tells us a lot about the patient’s visual, spatial and perceptual ability and their executive capacity,” she said.

It also reveals hidden problems. A recent study by Price and colleagues published in the Anesthesia & Analgesia journal, for example, found that 23% of patients over age 65 had issues with their cognitive performance, although only 2% had a note in their medical charts indicating such a problem. Patients unable to properly complete the task are referred to a specialist for further consultation.

“We never say no to a surgery; that’s not our job,” Price said. “Instead, we give this information to the patient’s doctors so they can make an informed decision.”

On rare occasions, the patient or their medical team will opt to forgo the procedure.

Price published a case study of a patient who chose not to have an eye surgery because he’d suffered delirium after previous surgeries.

“There are also times when a cognitive decline can wipe out the benefits of even a successful surgery,” said Dr. Dawn Hui, professor of cardiothoracic surgery at UT Health San Antonio. “We’ve had conversations with the families who’ve decided that the quality of life would be so much worse, it’s not worth doing an operation.”

More commonly, however, the medical team, armed with the knowledge that the patient may be at higher risk, will take steps such as more carefully monitoring the depth of the patient’s anesthesia. They may, for example, give it to them intravenously rather than inhaled through a mask. They also may administer lower doses of medications, such as those for nausea and pain, that can contribute to post-surgical delirium.

Scan results may also suggest specific communication strategies for patients. Doctors and nurses may need to repeat information several times for patients having memory problems, or give them instructions in writing.

“We can also flag patients who may need to be seen by a geriatrician,” Price said, referring to a physician who specializing in caring for older adults. “They basically get more heightened care.”

While such presurgical cognitive screening is recommended, it’s not required and so is not done universally.

It’s Price’s hope, then, that this will eventually change.

“We’re living longer and having more surgeries and there are new pharmaceuticals and new interventions available,” she said. “We need to pay extra attention to the vital organ that is anesthetized and takes the brunt of the stress of the body when it goes to a surgery procedure.”

Richard A. Marini is a features reporter for the San Antonio Express-News. He can be reached at rmarini@express-news.net.