Abstract
Introduction: Following the stressors of surgery and general anesthesia, the aging brain is at increased risk for developing postoperative cognitive dysfunction. The elderly population (older than 65) is particularly vulnerable to neurologic injury at a cellular level post-operatively from anesthesia. One disorder caused by damage to the brain is aphasia, or the inability to form language.
Case Description: An 88-year-old Caucasian male with a significant medical history of coronary artery disease, valvular heart disease, atrial fibrillation, hypertension, hyperlipidemia and stage 3 chronic kidney disease was admitted to the hospital for a left hip debridement. Five weeks prior to this admission the patient underwent a left hip hemiarthroplasty. On primary survey, the patient was alert and oriented, and the left hip wound appeared dehisced and infected. The patient subsequently underwent a left hip debridement. Following the procedure, the patient reported he was having visual hallucinations. On the third day of hospitalization, the patient reported resolution of these hallucinations and underwent a second incision and drainage (I & D) procedure of the same left hip wound. One hour following this procedure, the patient began to form involuntary nonsensical vocalizations. Nursing noted the patient making intermittent, incoherent, rapid syllable noises interspersed into his baseline speech pattern. The patient’s insight and judgment, however, remained intact and he expressed frustration with his aphasia. On evaluation by neurology, no focal deficits were noted, but the patient admitted to recurrence of auditory and visual hallucinations. On the fifth day of hospitalization, the patient underwent a third I & D procedure. Again, following this procedure, the patient continued to demonstrate intermittent episodes of his nonsensical speech pattern as well as increasing confusion. After the third I & D procedure the patient was deemed stable from an orthopedic point of view. In order to elucidate the cause of the neurological symptoms, labs were drawn and CT imaging was obtained. The patient’s labs demonstrated a TSH of 64.6, free T4 0.4, free T3 1.7, and a creatinine of 4.4, indicating hypothyroidism and worsening kidney function (baseline creatinine was 2.5). The CT brain demonstrated atrophy with an old right parietal infarct, but no acute abnormalities. The patient underwent hemodialysis, but his encephalopathy did not improve, and his intermittent expressive aphasia persisted throughout the hospital course.
Discussion: Due to the complexity of this case, the aphasia may be of multifactorial etiology ranging from deteriorating kidney function or elevated TSH to undergoing anesthesia or possible transient ischemic attack. This presentation offers a rare intermittent occurrence of a speech disturbance in a fully aware patient that can normally converse in between episodes. Furthermore, the potential for postoperative aphasia should not be overlooked in elderly patients, as it may be precipitated by an underlying condition.
