Expert: JM Starkman, MD - 6/6/2009

Question
Dear Doctor,
Thank you for sharing your professional knowledge here. My mom is 81YO, with PD and moderate Lewy Body Dementia. No other significant health issues;115#,pre-renal and wheelchair-bound. Because of chronic fecal impaction which responds only to enemas - and an inability to rule out GI obstructions with CT -the GI consultant suggests colonoscopy. PD experts warn of anesthesiology's impact on the CNS and recommend Versed for the procedure. LBD experts warn against the use of benzodiazepines.  

I would appreciate your thoughts on this.  Thank you again.

Lin


benzodiazepine

Answer
Your neurologist (the PD expert) probably has no experience anesthetizing PD patients--or ANY patients for that matter, so cannot be faulted for his incorrect versed recommendation. Versed is a poor choice for normal geriatric patients as its cognitive effects are considerably longer-acting in this population than in much younger people and cause an enormous degree of dysfunction as the elderly deal with prolonged amnesia and related residual benzodiazepine effects.  The problem is compounded in the already-compromised LBD elderly.

I suggest your mom be anesthetized by an anesthesiologist that you speak with before the colonoscopy:

The anesthesiologist you speak with should be THE ONE DONG THE ANESTHESIA, he should not simply hand-off the responsibility to an unconcerned nurse anesthetist or uninformed colleague who is not familiar with your concerns.

I have personally used a low-dose propofol (an anesthetic drug) technique to provide excellent anesthesia for this type of case.  I don't use any other medicine with it. It "wears off" very quickly with no residual.  This has worked well for virtually all elderly-compromised colonscopy cases I've done as long as the dose is kept minimal and only propofol is used---the elderly simply metabolize other medicines and combinations too slowly.

The gastroenterologist who does the colonoscopy should be amenable to this and should NOT be the one doing the anesthesia--he is trained as a GI expert, NOT an anesthesiologist especially credentialled to address complicated anesthetic issues like your mom.  But most gastroenterologists have configured their practices to work closely with anesthesiologists these days and leave the anesthesia to us.  If the gastroenterologist referred to you by your LBD expert is unamenable to working with an anesthesiologist that will work with you on these matters find another gastroenterologist/anesthesiologist!