Evaluating patient knowledge about peri-operative neurocognitive disorders (KNOW-PND study)

Introduction Anaesthesia remains a mystery for many patients, with common fears centred on intra-operative awareness or not waking up postoperatively. Although these concerns may be valid in specific circumstances, changes in cognition after surgery are much more prevalent. Peri-operative neurocognitive disorders (PNDs) are associated with poorer outcomes, extended hospital stays and reduced quality of life. The incidence of PND can reach up to 50% in specific patient populations.1 With an expected rise of the population aged 60 years and above by 2050, and with more than 300 million surgical procedures performed annually worldwide, the incidence of PND is anticipated to increase dramatically, with potentially high morbidity and mortality.2 In response to these concerns, the American Society of Anesthesiologists (ASA) launched the ‘Perioperative Brain Health Initiative’ (PBHI) in 2015 to raise awareness of PND.3 Although this initiative increased awareness among clinicians and provided information for patients and families, there are still limited data on patients’ knowledge of PND, which affects the use of interventions to improve PND. This study aimed to assess patients’ baseline knowledge of PND. Materials and methods This observational, cross-sectional, single-centre feasibility study assessed basic patient knowledge of PND. The study was registered on clinicaltrials.gov (NCT05590845), and ethical committee approval (AZ Sint-Jan Brugge Oostende AV Commissie voor Ethiek; Internal nr. 3085; Chairperson: Prof. Dr Ludo Vanopdenbosch; 23 December 2022) was obtained before patient recruitment. Patients were enrolled between February 2023 and June 2024. Inclusion criteria were patients aged 65 years and above, ASA physical status 1 to 3, scheduled for elective total hip replacement under general anaesthesia and including multimodal analgesia, peripheral nerve block and inhalation anaesthesia guided by processed electroencephalogram (EEG). Patients were excluded if they had insufficient proficiency in the Dutch language, pre-existing neuropsychiatric conditions or hearing impairment. Pre-operatively, an anaesthesia nurse obtained informed consent and gave the patients the survey with 15 yes/no questions regarding PND knowledge and perception. Following completion of the survey, patients received a standard pre-operative brochure addressing anaesthesia-related topics and delirium, and then the Telephone Montreal Cognitive Assessment (T-MoCA) was used to assess pre-operative cognitive function. The T-MoCA was repeated 6 weeks postoperatively. A score of less than 18/22 was suggestive of cognitive impairment.4 The study's primary outcome was to evaluate patient knowledge of PND complications. Descriptive statistics were used to report patient demographics, with data presented as mean ± standard deviation, median [interquartile range, range] and percentages, where appropriate. Parametric data were analysed using Student's t-tests, while nonparametric data were compared using Mann--Whitney U tests or Wilcoxon signed-rank tests with Bonferroni corrections. A P value of less than 0.05 was considered statistically significant. Reliability testing of the survey was performed using Cronbach's alpha. All statistical analyses were conducted using SPSS version 27 (IBM, Armonk, New York, USA). Results Twenty-nine patients were included in this study, of whom 15 (52%) had prior knowledge of PND. When asked about the causes of PND, 23 (79%) patients believed it was due to anaesthesia (Fig. 1). Twenty-six (86%) patients assumed that locoregional anaesthesia could reduce the risk of PND, and 22 (76%) patients believed certain drugs could increase its likelihood. Fourteen (48%) patients thought that treatment was available for PND.Fig. 1: Pre-operative patient knowledge and perception of peri-operative neurocognitive disorders (PND) (n = 29).Notably, patients who developed PND 6 weeks postoperatively were more likely to believe that locoregional anaesthesia could mitigate the risk of PND (P = 0.044) (Supplement Table 1S, https://links.lww.com/EJAIC/A125). Only two patients (7%) reported that their surgeon had mentioned the risk of PND pre-operatively, yet 26 (90%) expressed a preference to be informed about PND before surgery (Fig. 1). In addition, 15 patients (52%) indicated that they would notify a caregiver about the risk of PND. Discussion This study provides insight into patients’ knowledge and attitudes towards PND, revealing that while half of the participants had some pre-operative understanding of PND, they had significant misconceptions. A key finding was that 79% of patients believed anaesthesia was the sole cause of PND, indicating a limited understanding of the multifactorial cause of this disorder. PND is influenced by various factors, including surgical stress, pre-existing conditions and postoperative management.5 This gap in patient knowledge highlights the importance of improving educational resources provided to patients before surgery and the need for further engagement from physicians, government agencies and other key stakeholders. Furthermore, 86% of patients believed that locoregional anaesthesia could lower the risk of PND, even though evidence from a recent large randomised controlled trial (RCT) shows that brain health outcomes after general versus regional anaesthesia are not significantly different.6 It is also concerning that only 7% of patients were informed about PND by their surgical team, whereas most patients expressed a desire to be informed pre-operatively about PND. This finding emphasises a need for improved communication between healthcare providers and patients regarding potential neurocognitive complications. Several strategies should be considered to strengthen communication and support shared decision-making. These include implementing standardised pre-operative counselling protocols, incorporating discussions of PND into the surgical consent process and utilising structured conversation aids to enhance patient comprehension.7 In addition, fostering interdisciplinary collaboration between anaesthesiologists, surgeons and peri-operative nurses could help ensure that PND education is consistently and effectively delivered throughout the patient's surgical journey. This study has several limitations. As a single-centre feasibility study with a small sample size of 29 patients, the generalisability of the results is limited. Logistical constraints prevented further expansion of the sample size during the study period. In addition, the low Cronbach's alpha values (0.228 and 0.263) indicate that the internal consistency of the survey was suboptimal, emphasising the need for further refinement of the survey tool to enhance reliability. Finally, although the study included an informational brochure on anaesthesia and delirium, its effectiveness in enhancing patient understanding was not assessed. In short, this feasibility study aimed to assess patient recruitment, follow-up and the acceptability of screening methods. Rather than achieving statistical power, it identifies operational and methodological challenges to guide a future large-scale trial. Conclusion This single-centre feasibility study, though limited by its small sample size, highlights significant patient knowledge gaps regarding PND. These findings demonstrate the need for targeted patient education to enhance understanding and engagement in peri-operative care. Studies with larger and distinct patient populations are warranted to validate and build upon these results, ultimately supporting informed decision-making and optimising peri-operative brain health.

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