Sunday, May 3, 2026

Pakistan International Airlines Plane Crashes In Karachi

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KARACHI, Pakistan (Reuters) — A Pakistan International Airlines (PIA) plane with around 100 passengers and crew crashed on Friday in a residential area of the southern city of Karachi, with many feared dead, officials said.

The state carrier said flight PK 8303 had crashed with 99 passengers and eight crew members on board, though civil aviation officials said the total for both may be 99.

“The last we heard from the pilot was that he has some technical problem,” PIA spokesman Abdullah H. Khan said in a video statement. “It is a very tragic incident.”

A senior civil aviation official told Reuters it appeared the plane was unable to open its wheels due to a technical fault prior to landing, but it was to early to determine the cause.

Geo TV broadcaster showed crowds near the scene, which appeared to be a densely populated area, and ambulances trying to make their way through.

Black smoke billowed and several cars were on fire.

The Pakistani army said its quick reaction force and paramilitary troops had reached the site for relief and rescue efforts alongside civil administration bodies.

(Asif Shahzad reported from Islamabad; Editing by Toby Chopra and Andrew Cawthorne)

This is a developing story. Please check back for updates.



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Warwick Thornton: the man and his demons, alone together

It’s not uncommon for actors, singers or bands to have “riders”, certain conditions that they write into their contracts which the hosting venue must fulfil. Queen once asked for a mud-wrestling ring outside the dressing-room to provide them with some post-show entertainment. Punk icon Iggy Pop once requested “somebody dressed as Bob Hope” to do impersonations of the dead comedian. Most famously, the rock band Van Halen demanded that at every show a bowl of M&Ms be provided in their dressing room, with the brown ones removed. Failure to do so would result in the show’s summary cancellation.

Filmmaker Warwick Thornton’s needs are more prosaic. “When I’m on location, I always ask the producer for a unit with a stove, or a house with a kitchen,” he says. Thornton is no diva – he’s not going to start smashing cameras if he doesn’t get access to a hotplate – it’s just that cooking makes him work better. On shoots, he has been known to make meals for the cast and crew as a sign of his appreciation. He cooks for people to engender familiarity, to foster creativity and, on a more personal level, as a reset, “a way”, he says, “of erasing the day. If I don’t cook at the end of the day, I’ll lie awake worrying about what I’ve shot.” And we’re not talking about throwing together a French omelette or a 10-minute stir-fry. “I might go to bed at 11pm, because it’s taken three or four hours to cook a meal.”

It seems to be working for him. Over the past decade or so, Thornton, who is 49, has emerged as one of the strongest voices in Australian film. His first feature, Samson and Delilah, a tough love tale set in a remote Aboriginal community, won the Camera d’Or at the Cannes Film Festival in 2009. His second major release, the brutal western Sweet Country, in 2017, won prizes at two of the world’s leading festivals, Venice and Toronto, and took best film at the Asia Pacific Screen Awards. Thornton has also made short films and major art installations, and is, to boot, a talented cinematographer, with a “warm, fresh eye”, as actor Bryan Brown puts it, “and a gift for producing scenes of mesmerising beauty”.

He also has a gift for excess. “I live a pretty fortunate life through cinema and art, so I can have a rock ’n’ roll party every bloody night if I want to,” Thornton tells me. “I love the after-party, the bar stool, the pool table, the conversation. It’s all just too exciting.”

We are sitting at a glass-topped table on the cracked concrete landing of a house that his older sister Erica rents in Annandale, a much sought-after suburb in Sydney’s inner west, where Thornton lives when he is not out making movies. I’d been expecting a tastefully appointed terrace house, boho meets Vogue Living, but this place looks more like a student bedsit, with blankets over the doors and garage-sale furniture. There’s a jumbo-sized packet of Coco Pops on top of the fridge, right next to a bottle of Tanqueray. “It’s not the anal-bleached version [of an Annandale home],” he says. “That’s not my thing.”

Thornton is an intimidating figure, standing well over six feet tall and dressed almost entirely in black; black jeans, black cap, black boots, black cowboy shirt. The only exception is his T-shirt, which is brown. He is fearsomely hairy, with a beard and swarming neck growth that appears, at least from where I’m sitting, to have grown into and become part of his T-shirt, giving him the aspect of a chain-smoking grizzly bear. “I’m like the ogre under the bridge,” he says. “Sometimes they have to drag me out to have a shower, and then I go off to work.”

His internal ogre is abetted, to some extent, by his encumbered lifestyle: he has three kids – Luka, 16, Rona, 23 and Dylan, 27 – by two different women, but he lives alone, providing him with ample latitude to over-indulge. “It’s drinking, mainly. I love it,” he says. “I’ve had little interventions, from mates and my two sisters. They were like, ‘Hey Warwick, I love you, and I want to grow old with you and for us both to be 80 and sitting on the verandah having a beer, but the way I see your life going, that ain’t going to f…en happen.’ ”

A reality check was required, a spiritual and physical detox, which is how he ended up making his latest project, The Beach. Part nature documentary, part memoir, part rehab chronicle, The Beach, filmed in May last year, follows Thornton’s transformation as he spends more than a month in a tin shack on a remote beach in Western Australia. In six half-hour episodes, we watch Thornton reckoning with his past, his time growing up as an Indigenous kid in Alice Springs, his flaws, his strengths and his many scars, both internal and external. “We didn’t really go out there with any preconceptions,” he says. “I just knew I wanted to do it, I had to do it.”

Warwick Thornton during the month-long filming of The Beach in Western Australia’s Dampier Peninsula.Credit:Susan Stitt

The Beach follows in a long tradition of wounded souls who seek redemption by submitting to the wilderness. In Thornton’s case, this meant a one-room shack on the tip of a sand spit surrounded by the dunes, mangroves and ocean of the Dampier Peninsula in the state’s north-west. As settings go, it’s outrageously beautiful. Viewers spend a lot of time in the hut, which was built with help from the local Indigenous community of Lombadina and which, despite the Robinson Crusoe conceit, is a minor- or masterpiece of scavenger chic, with wicker baskets propped against the walls, and coils of old rope hanging from the corner posts.

Those expecting the bare-knuckle narrative of Sweet Country will be disappointed. The Beach is slow television, with plenty of long takes and cryptic silences. The effect can be either meditative or maddening, depending on your mood. Not surprisingly, cooking is a big part of it. Thornton brought along three hens for eggs, not to mention an extensive collection of condiments and sauces, together with an array of vintage cooking implements – an iron griddle, some enamel tins and a blackened brazier.

He was, however, expected to catch all his other protein. “That shack didn’t have a fridge or any power,” he says. “So if I didn’t catch anything that day, then I’d have been having steamed rice.” We see his faltering, farcical attempts at spearfishing and cutting coconuts open. His patience wears thin, especially at the beginning, due to boredom and lack of booze. His only vice: cigarettes. “We were already struggling with there being no alcohol and me not being the great black hunter. If I hadn’t been able to smoke, I would have stabbed the whole crew to death.”

When Thornton likes something, he calls it “rock ’n’ roll”. Even things that might not seem especially great, like depression, can turn out to be “rock ’n’ roll”.

After a time, the therapy worked. “I could see the transformation in Warwick,” says co-producer Michelle Parker. “He started to drop some weight. He became lighter, brighter, fitter, happier. His eyes were clear and twinkling. He was even doing yoga.”

Parker was part of a skeleton crew, which included Thornton’s cinematographer son, Dylan River, who shot the whole series. The crew spent most of the day filming with Thornton, before returning at night to Lombadina, about half an hour’s drive away. “We didn’t know how Warwick would handle the whole experience,” says Parker. “Whether he would be angry, upset or have severe withdrawals. Sometimes he would just say, ‘I’ve had enough, just leave me alone,’ and we’d retreat.”

The poise of River’s cinematography is a joy in itself. But among the most affecting elements are the stories, or impromptu soliloquies, that Thornton addresses to camera.

One of them concerns a man he calls Uncle Kingy. Kingy was a ngangkari, a traditional healer, whose job was to help people whose spirits had left them due to illness or accident. Kingy would go out, catch their soul and put it back in their body. When Thornton was growing up, Kingy was hugely respected and much in demand.

Years later, Thornton was driving down the main street of Alice Springs when he saw him walking along, drunk, yelling and screaming. Thornton thought he should offer him a lift, but he didn’t. “I thought, ‘I’ll leave him, because he’s pissed and he’ll want to bludge money off me, and then make me drive him around everywhere.’ ” The next day, Thornton flew out to a shoot. The day after that, he heard that Kingy had died. Thornton was riven with guilt: “The last time I saw old Kingy, I didn’t want to pick him up.”

Thornton became so angry with himself that he went and bought a “big knife”, took it back to his hotel room, and started slashing at his upper arms. Every time he cut himself he thought of Kingy, “what an amazing man he was, and what a f…en dickhead I am”.

When I heard Thornton tell this story on The Beach, I thought it might have been embellished. So when I interview him, I ask to see his arms. The scars are there, all right, more than a dozen of them, thick and raised like lengths of cord buried in his skin.

Sweet Country, Thornton’s second feature film, received a five-minute ovation at the 2017 Venice Film Festival.

Sweet Country, Thornton’s second feature film, received a five-minute ovation at the 2017 Venice Film Festival.Credit:

Thornton grew up the youngest of five children in Alice Springs, a notoriously tough town that sits like a blistered bullseye in the centre of the continent. “Alice in the 1970s was a small place with not a lot to do,” says his sister, Erica Glynn, who is also a filmmaker. “We’d swim in the town pool in summer. Mum took us to the drive-in cinema. There was also a walk-in cinema. Back then, and also now to an extent, it was a racist little town, and so it was a difficult place to be for Aboriginal people.”

The family lived in a small single-storey fibro house, with a backyard that was so full of bindis you couldn’t play in it. For his seventh birthday Thornton asked for, and received, a huge pile of dirt. “It was the best present I ever had,” he says in The Beach. He played in the dirt pile for two years, making tunnels and fortresses in it, until it spread out and the bindis came back.

When he grew older Thornton rebelled, spending most of his time causing trouble and racing motorbikes with his mates on the claypans out of town. His mother, Freda Glynn, was a pioneer of Indigenous film, TV and radio, a co-founder of the Central Australian Aboriginal Media Association (CAAMA), which includes Imparja Television. In an effort to straighten her son out, she sent him, at the age of 13, to school in New Norcia, Australia’s only monastic town, 132 kilometres north of Perth.

When he returned, two years later, he got a gig as a DJ on Green Bush, one of CAAMA’s most popular radio programs. Green Bush played music, “a lot of requests, mostly from prisoners”, Thornton says. But it was more than a radio station. It broadcast to remote communities that might have had only one telephone box and where many people didn’t know how to read or write. Rather than simply playing music, then, the station became like a bulletin board or open telephone line. “You’d get requests like ‘G’day Warwick, can you play My Cheating Heart by Hank Williams, and can you tell my daughter that I’ll be out in three months and can she give me a call because I need to find a way of getting back to my community.’ ”

In 1983, CAAMA started a mobile video unit. By the late 1980s, Thornton had joined as a camera trainee, working alongside other future luminaries, including the sound recordist David Tranter, and Rachel Perkins, who would go on to direct hits such as Radiance and Bran Nue Dae. (Asked in an interview years later to describe what Thornton was like, Perkins said it was hard to say, since “he just used to grunt and not speak much”.) CAAMA’s film teams travelled widely “to all sorts of obscure places”, says Thornton. “We’d take swags, sleep by a campfire, getting bitten by scorpions and centipedes, and spend days filming as many stories as we could.”

“Warwick is a grumpy bastard. He’s not into small-talking or pleasantries. He’s a deep river, and spends a lot of time in his own private story world.”

David Jowsey, producer of Sweet Country.

Thornton and his colleagues often found themselves documenting vanishing worlds in real time. “You’d sit down with some old lady who’s living in a corrugated-iron humpy and she tells you her life story and then sings you a song that probably hasn’t changed in 30,000 years. And she’s got her great-granddaughter next to her, to teach her, ’cause she hasn’t sung that song in 30 years and she realises that she’s the last custodian. To see that happen, in front of you, that’s a privilege.” He says that filming in remote communities was a way of saying “You are worthy”. “You could see people’s eyes light up with the knowledge that someone had taken notice.”

In 1993, Thornton went to Sydney to study cinematography at the Australian Film, Television and Radio School. While still a student, he made Payback, a short black and white film about a fictional inmate, Paddy (George Djilaynga), who emerges from a long stint behind bars only to face tribal law. The film, which screened at the prestigious Telluride Film Festival, was followed by his work as a cinematographer on the documentary, Marn Grook: An Aboriginal Perspective on Australian Rules Football. He also worked as the cinematographer on Perkins’s directorial debut, Radiance.

Then, as now, he had a reputation for gruffness. “Warwick is a grumpy bastard,” says David Jowsey, who produced Thornton’s feature film, Sweet Country, and who worked with him on the television series Mystery Road, three episodes of which Thornton directed last year. “He’s not into small-talking or pleasantries. He’s a deep river, and spends a lot of time in his own private story world.”

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Thornton’s range is unusually broad. His short films can be tender, even funny. Nana, a six-minute film he released in 2007, paints a whimsical portrait of a no-nonsense matriarch as seen through the eyes of her granddaughter. Mimi, in 2002, featured Sophie Lee as a clueless collector of Indigenous art. But his two feature films, Samson and Delilah, about a blighted love affair between two petrol-sniffing teenagers, and Sweet Country, about an Indigenous station hand who is put on trial for killing a white man, are so tough you could break your teeth on them. With its mix of bracing realism and a painterly aesthetic, Sweet Country made Thornton’s name. When the film was shown in Venice, it was lauded as a landmark for Indigenous filmmaking.

“I remember being in that cinema in Venice with Warwick when it was shown,” says Bryan Brown, who played Sergeant Fletcher in the film.

“When it ended, everyone turned around to where we were sitting and applauded for five minutes. I thought, ‘Wow, when Warwick was a young fellow running around Alice Springs in bare feet, we’d all have thought he had a 50/50 chance of being dead or in jail by the time he was 30. But here he was on one of the most sophisticated stages in the world.’ It was him saying, ‘You know what? I don’t have to give in to what everyone else expects. I can be different.’ ”

While filming The Beach, Thornton, who loves to cook, had three hens to supply eggs, but had to catch any other protein – a task he struggled with initially.

While filming The Beach, Thornton, who loves to cook, had three hens to supply eggs, but had to catch any other protein – a task he struggled with initially.Credit:Susan Stitt

When Thornton likes something, he calls it “rock ’n’ roll”. Making films is “rock ’n’ roll”. Cooking is “rock ’n’ roll”. His family is “rock ’n’ roll”. After-parties are, needless to say, “totally f…en rock ’n’ roll”. Even things that might not seem especially great, like depression, can turn out to be “rock ’n’ roll”. Winston Churchill called his depression the “black dog”. In The Beach, Thornton describes it as his “little black puppy”. He explains how every now and again, “sometimes it’s three years, sometimes it’s three times a year”, he will hear that little black puppy outside, at the foot of his door, mewling and moaning, wanting to come in. But Thornton doesn’t answer it. The puppy gets hungrier and hungrier, and it scratches harder and harder. But still Thornton resists the urge to let it in. He has learnt that to accommodate that little puppy, to feed it, entertain its needs, would be inviting disaster. Better to lie in bed and wait until it stops scratching and crying.

“And when I know that’s happened,” he says in The Beach, “the puppy’s dead, and I can open the front door. And then I can go back out into the world.”

Sitting in his sister’s backyard in Annandale, I suggest that the “little black puppy” might have something to do with booze. “No,” he says. “I don’t blame that on alcohol.”

“But booze is a known depressant,” I say.

“Nah. [The depression] is just rock ’n’ roll, you know what I mean.”

“No,” I say, “I don’t know what you mean.”

“Well, it’s got nothing to do with alcohol. If I stopped drinking I’d be f…en eight times more depressed.”

This might sound ridiculous coming from anyone else, but with Thornton it has a certain Hemingway-esque plausibility. At one stage he tells me that if “someone says anything bad about me … I just go punch them in the head. It’s horrific. We don’t live in that world any more. [But] that’s how I grew up.”

“We’d all have thought he had a 50/50 chance of being dead or in jail by the time he was 30. But here he was on one of the most sophisticated stages in the world.”

Bryan Brown

He has a similarly muscular, two-fisted approach to his work. In 2010, he told a journalist that he was concerned that the Southern Cross was becoming “the new swastika”. The Nazis appropriated the swastika, which had for millennia been a Hindu symbol for good fortune, and made it synonymous with fascism. According to Thornton, right-wing nationalists in Australia had done the same thing with the Southern Cross, turning what for Indigenous people has long been a cosmological beacon into a racist emblem.

His comments, which came following his 2010 nomination for Australian of the Year, caused an uproar. “I went and hid in a cupboard for a while,” he later told the ABC. “And then over a couple of years, I got angry.” In 2017 he emerged with a documentary, called We Don’t Need a Map, that examined Australia’s fraught relationship with the Southern Cross and its use and abuse since colonisation.

“Warwick is very conscious of the history of Australia, and what has happened to his people,” says David Jowsey. “He also has an ironic, sardonic, witty take on White Australian culture.”

Take Ned Kelly. “If Ned Kelly were alive today,” Thornton has said, “he’d be a meth-head holding up a 7-Eleven.” For this year’s Biennale of Sydney, Thornton made a film installation deconstructing the bushranger’s legend, showing Kelly robbing a 7-Eleven, overlaid with readings of jingoistic White Australia-era poetry and verse. (The installation was on show for 10 days before closing due to COVID-19.)

Making this kind of art takes a certain self-confidence, or at least a thick hide. “People say he’s got a big ego,” says his sister Erica, “but he’s a leader, and one of the requirements of that is that you have to self-sell. I want to run and hide from all that, but he’s really taken it on, and it’s one of the reasons he is where he is.” She mentions The Beach: “That’s courageous, exposing yourself like that, but probably more than that, exposing a little bit of arrogance thinking that people would care enough about it.”

To an extent, whether audiences take note is beside the point. One of an artist’s chief obligations is to take risks, and Thornton has delivered on that. Besides, The Beach was always going to fall somewhere between art and therapy. “It’s important to slow down and look at your life,” he says. “To think about who you are – the empowering moments and the absolute f…ups that I’ve made, and how they are all part of who I am today. And The Beach gave me that space.”

It also allowed him more clarity, and to be more honest with himself about what he can change and what he can’t. After a month in the wilds, Thornton returned to civilisation, which in this case meant Broome. One of the first things he did was go to the pub, put some trifectas on and order a beer.

“That’s the reality,” he says. “But you know what? I didn’t stay at the pub till I was maggotted, or until I’d had 12 beers. I stayed for three beers. I lost the trifecta, walked out of the pub, went to a restaurant and had something to eat with a glass of wine.” His internal ogre had found a degree of peace. “Maybe. It was just that I didn’t need to get f…ed up. I didn’t need it, and that was the most important thing.”

The Beach airs on NITV and SBS on May 29 at 7.30pm.

To read more from Good Weekend magazine, visit our page at The Sydney Morning Herald, The Age and Brisbane Times.

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An alleged child abuser died before his trial. His accusers are now being blamed

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Kampala, Uganda — When she heard the news of her abuser’s death, Hope said that she felt like her heart had stopped beating for a few seconds. “I didn’t know how to respond. I was broken, I shivered. I didn’t know whether to believe it or not, to cry or not,” she wrote to CNN.

Hope is one of the young women and girls who for the past year have been traveling to Ugandan courts ready to testify against German national Bernhard “Bery” Glaser, who is alleged to have sexually abused vulnerable girls like her, who were living in his care.

“I credit him for the good deeds he did but no one is perfect, there is also a dark side of him and that’s what people have failed to understand,” said Hope, whose name has been changed to protect her identity.

Glaser died in early May at Murchison Bay Hospital, a facility treating inmates of Luzira Prison in Kampala, Uganda. The day before his death, he had been granted bail, including international leave for medical treatment for stage four skin cancer.

He had been detained since last February, when he turned himself in, and charged with 19 counts of human trafficking, then formally charged and arrested in April with 19 counts of human trafficking, seven counts of aggravated defilement, one count of indecent assault and one count of operating an unauthorized children’s home, known as ‘Bery’s Place.’ He was first arrested in 2013, but the case was dismissed when survivors and their parents did not appear in court to testify.

“Obviously, Bery’s condition was serious and we feel for his family during this time. But, we also feel saddened for the victims in this case, and there are many,” said Rachel W. Bikhole, Uganda’s Assistant Director of Public Prosecutions, who described the evidence against the accused as “overwhelming.”

Bikhole told CNN that when a search of ‘Bery’s Place’ was carried out in February 2019, Glaser’s laptop was recovered and subjected to examination, during which naked videos and photos of the victims — some as young as five years old — were found on it. When questioned, Bikhole said Glaser claimed the material was used for fundraising purposes.

“These girls and young women will not see the day that Bery was held accountable for his crimes.”

Rachel W. Bikhole, Uganda’s Assistant Director of Public Prosecutions

Investigators also found email and Facebook messages on Glaser’s computer from him to a key witness in the 2013 case offering her money not to testify, according to Bikhole. CNN has reached out to his lawyer for response.

“These girls and young women will not see the day that Bery was held accountable for his crimes,” added Bikhole. “They will not get to tell of the terrible sexual abuse they endured for so many years and the lasting impact it has had and will have on them for the rest of their lives.”

Lawyers supporting the prosecution and a police source told CNN earlier this year that Glaser’s trial was postponed due to delaying tactics by the defense such as applying for a plea bargain deal and requesting a Flemish interpreter despite his demonstrated English proficiency. As a result, he did not make a plea before his death. Glaser’s lawyers have denied attempting to delay proceedings. In a February statement sent by WhatsApp to CNN, a lawyer representing Glaser denied that he had committed the alleged crimes.

Patricia, another survivor whose name has also been changed, told CNN that she had “never missed a court session,” traveling to testify in Kampala and Masaka eight times — only to be told again and again that the case would again be adjourned.

“We ended up performing poorly due to the trauma and endless journeys to court, resulting in us missing out on exams,” said Patricia, 20, who says she was abused from the age of 11 and is now at university.

Hope described the past year as a “very difficult year of abuse and accusations.” After speaking out about their experiences, survivors like Hope and Patricia have been victim-blamed and had their testimonies called into question, including in some Ugandan media reports and social media.

Before they had time to process the news of Glaser’s death, Hope said she and other witnesses started to receive calls and messages with threats and curses, labeling them “murderers.”

As reported in a CNN investigation into the case in February, Asia Namusoke Mbajja — a social worker with connections to Bery’s Place who eventually reported Glaser — has opened a police case of offensive communication and threatening violence following similar interactions.

The case is ongoing, with five phone numbers used to threaten to “injure or harm” Mbajja under investigation — including one registered in the name of Glaser’s wife, Ingrid Dilen, according to a preliminary police report see by CNN. Dilen told CNN she has not threatened anyone.

Mbajja too has received a fresh barrage of threats following Glaser’s death, and government prosecutor Bikhole also told CNN she has been “attacked a lot” and received threats on social media.

“I want to hide, I want to run, run far away so that no one will ever find me,” wrote Hope. “But is this the right thing? I’m just a witness,” she said, adding that even “a simple thing from him just to say sorry to us” would have meant so much. Hope also told CNN that she is struggling to support the other survivors, many younger than her, who she is currently living with at a shelter.

“I can’t lend them a shoulder to cry because I also need one to cry on,” she wrote.

“We will continue to find ways to help these victims,” said Bikhole. “And we will continue to fight against trafficking in persons in Uganda as there are still many cases and victims that require our attention.”

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Reducing your risk of changes in thinking following surgery – Harvard Health Blog

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Cognition is an important function of the brain that enables us to acquire and process information, to enhance our understanding of thoughts, experiences, and our senses. Any condition that affects our ability to think, reason, memorize, or be attentive affects our cognitive ability. Some cognitive decline is a normal part of aging, but there are many things you can do to prevent or forestall cognitive changes as you age, including when planning for surgery.

Older adults are having more surgical procedures

As our population ages and medicine and healthcare advances, more older adults are likely to develop serious conditions (like heart problems) and undergo surgical procedures to treat or manage these conditions. Recent surveys suggest that progress in surgical techniques and control of anesthesia has increased surgical procedures in older people, with approximately 30% of all surgeries being conducted in people over the age of 70.

While advances in medicine may help people live longer, older adults are more likely to develop complications due to surgery. Some research suggests approximately one-quarter of those over 75 undergoing major surgery will develop significant cognitive decline, and about half of those people will suffer permanent brain damage.

Why do surgery and anesthesia cause problems with thinking for older adults?

There are degenerative changes in the brain with aging that predispose people to cognitive changes from surgery. Hence, age is a risk factor that needs to be considered when making decisions about surgery. Education level, mental health, and pre-existing medical conditions are also factors that affect an older person’s postsurgical cognitive functioning. People with higher levels of education tend to have more active brains due to regular mental stimulation. Mental and social activities promote brain health and decrease the risk of dementia and cognitive decline with normal aging.

Pre-existing medical conditions such as obesity, hypertension, coronary artery disease, diabetes, chronic kidney disease, stroke, and dementia predispose older adults undergoing surgery to more risk of postoperative cognitive decline. The reason these diseases cause cognitive decline is related to systemic inflammatory markers in the blood — proteins that are released into the bloodstream as a result of inflammation in the body. These markers enter the brain following a break in the blood-brain barrier (protective membrane) during the postoperative period, resulting in inflammation in the brain. This blood-brain barrier dysfunction is frequently seen in older people (even in the absence of surgery), and has been seen in approximately 50% of patients undergoing cardiac surgery.

Does the type of surgery and anesthesia matter?

Many surgical factors and techniques, blood pressure fluctuations during surgery, and longer time in surgery can adversely affect the cognitive function of older patients. Each factor affects cognitive functioning in a unique way. Younger patients tend to respond better to surgical stresses compared to older people.

Minor surgical procedures such as skin biopsies, excision of cysts, suturing of lacerations, and related procedures performed on an outpatient basis are unlikely to result in cognitive decline. However, as the complexity of a surgical procedure increases, with longer operative periods and greater exposure to more anesthesia medication, the likelihood of postoperative cognitive decline increases. This is especially true for cardiac surgery.

Studies suggest that incidence of postoperative cognitive decline is approximately 30% to 80% after cardiac surgery, while for noncardiac surgeries the prevalence is approximately 26%. While all major surgeries (such as orthopedic, abdominal, or gynecological) pose a risk for cognitive decline, cardiac surgeries have a much higher proportion of cognitive decline after surgery. The most common determinants of cognitive decline involving cardiac surgical procedures are the presence of pre-existing cognitive dysfunction and the use of bypass machines to replace the function of the heart and lungs during the surgery.

Anesthesia management before and during surgery affects what happens after surgery

The perioperative period refers to the time span of a surgical procedure, and includes three phases: preoperative, operative, and postoperative. Anesthesia management encompasses all three phases. The type and dose of anesthesia medication, the use of opioid analgesics, fluid, and glucose management can all influence a person’s cognitive function in the perioperative period. The use of multimodal anesthesia (where a combination of intravenous medications is used, instead of only inhaled agents) may protect against some cognitive dysfunction, as may using non-opioid analgesics for pain management in the postoperative period.

Are there strategies to avoid cognitive decline in the postoperative period?

Benjamin Franklin once said, “An ounce of prevention is worth a pound of cure.”  No other condition exemplifies this saying better than preventing postoperative cognitive decline.

The following are some strategies you and your caregivers can use to prepare for surgery.

Before surgery is scheduled:

  • Eat healthy, balanced meals. Foods rich in polyunsaturated fatty acids are protective for your brain health.
  • Exercise regularly, or as much as allowed by your cardiac conditions. Physical activity promotes brain health.
  • Maintain a healthy weight.
  • Remain socially active and connected.
  • Reduce stress. Meditation significantly reduces stress and promotes a sense of calm and overall well-being.
  • Practice good sleep habits and try to get six to eight hours of sleep a night.

When surgery is scheduled:

Schedule a comprehensive geriatric assessment. This enables your physician to diagnose reversible aspects of frailty preoperatively (if they exist) and take adequate measures in a timely manner, such as altering medications you may be taking, and/or postponing surgery if you are extremely frail, to improve nutrition and incorporate lifestyle changes.

Talk to your surgeon about the risks and complications of the procedure. If you are having heart surgery, ask if a cardiopulmonary bypass machine will be used, and whether it is important to your surgery.

Talk to your anesthesiologist about

  • The types of medications they plan to use, and if there are alternatives for those medications. Have a conversation about need for opioid analgesics, and if alternative non-opioid pain medication can be used to decrease the risk of postoperative cognitive decline.
  • The methods of measuring medications that can reduce your risk of cognitive changes. For example, use of EEG machines during surgical procedures enhances the anesthesiologist’s ability to monitor the depth of anesthesia. Anesthesia depth is the degree to which the central nervous system is depressed by an anesthetic medication. EEG monitoring will result in adequate usage of anesthetic agents, avoid overuse, and reduce risk for postoperative cognitive decline by reducing anesthesia exposure.
  • Gather relevant information on your perioperative management. Discuss which medications you currently take and should continue taking, and which ones should be avoided.

After surgery and during recovery:

Caregivers need to be informed about the need for keeping their loved one active and following physical rehab recommendations, and providing mental stimulation in the postoperative period. Puzzles, sudoku, board games, books, etc., will keep someone entertained while simultaneously providing them with some brain activity.

Finally, it is necessary to understand that although there is no cure for postoperative cognitive decline, preventive strategies and pre-planning with your team of surgeons, anesthesiologists, and geriatricians can help reduce the risks of cognitive problems that older adults often face following surgery.

References

Impact of frailty on outcomes in surgical patients: A systematic review and meta-analysis. The American Journal of Surgery, August 2019.

Postoperative cognitive dysfunction — current preventive strategies. Clinical Interventions in Aging, November 8, 2018.

Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology, October 2018.

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