#also give for me always has this underlying.. not aggression but.. controlled anticipation.. the moment before the explosion feel

[a-s-levynn]

"I'll tear the fibre from the filament / I'll be the limit of your light again" A Series of Small Offerings - II/7 - day15

[quizblr]

(thanks to @thegloriousdarklord​ for sending this to me)

This is an absolutely amazing writeup on counterphobic 6.  I had to share it.  Found here, credit to Beatrice Chestnut.

The Sexual Six -"Strength/Beauty" (Countertype)

The countertype of the Type Six subtypes, the Sexual Six is the most counterphobic Six, the one who turns against the passion of fear by assuming a stance of strength and intimidation. Instead of actively feeling fearful, these Sixes have an inner belief that when you are afraid, the best defense is a good offense. As Naranjo explains, anxiety in this Six is allayed by skill and readiness in the face of a possible attack. They often appear bold and even fierce. They go against danger assertively, and even aggressively, as a way of denying and coping with their (often unconscious) fear. Through denying their feelings of fear to one extent or another, Sexual Sixes go against danger from a position of strength; therefore, they have a passion for searching for or securing a position of strength. And it's not just a strong character they seek, but the kind of strength that makes somebody else afraid-they want to assume a powerful enough to hold the enemy at a distance. These Sixes display a forcefulness that comes from no wanting to be weak, and they don't allow for weakness in themselves. Sexual Sixes' strength is often physical. They may develop this physical strength through sports or exercise that serve to build muscles and make them feel strong in their bodies. They tend to have marked control over their bodies as a way of cultivating a sense of inner strength to guard against feeling the chaotic emotions associated with the release of rage or other impulses. Theses Sixes also seek to be strong in terms of endurance; they seek to feel tough in the face of fatigue, oppression, humiliation, and pain. (In this aspect, they may resemble the Self-Preservation Four.) For the Sexual Six, strength is often directly connected to an illusion of independence and a sense of being able to remain "unscathed" by trouble. They may also have a feeling of being somehow "bad" inside, and their strength protects them from their own inner attacks on themselves. Sexual Sixes have a need not just for strength but for intimidation. As Naranjo suggests, this expression of intimidation is very much the essence of the character; if they appear strong, they won't be attacked. While Naranjo explains that Ichazo's title for this subtype, "Strength/Beauty," originally meant "strength" in men and "beauty" in women, it may also be true that being beautiful is a source of strength in both male and female Sexual Sixes. These characters walk around with the idea that anyone can become dangerous, so they do everything they can to not feel cheated, manipulated, taken advantage of, or attacked. If you are someone who thinks and feels this way, you need to be prepared to be strong and mount a resistance. That's why Sexual Sixes not only develop strength but also intimidations-in the service of resistances, of being prepared to scare someone off, rebel, or be contrary. Sexual Sixes give off the impression that they could get violent with anybody at any time, but that doesn’t mean that they have no fear. It is precisely out of a sense of fear that their anticipation of an attack comes-there is a somewhat paranoid imagining of danger, a belief that anyone can turn into a threat. However, these Sixes usually do not look afraid; their visible character could hardly be called "fearful" from the outside. In contrast to the Self-Preservation Six, who backs away from threats, the couterphobic Sexual Six tends to move toward risky situations, feeling a sense of safety in actually confronting danger rather than hiding from it or avoiding it. They convince themselves (and others) that they are not victims of fear; they are convinced that fear is an emotion that should be eliminated systemically. Despite being aggressive as part of their effort to intimidate through strength, Sexual Sixes tend not to acknowledge their aggressive side and may not be aware of it-or at least of the intensity of it. Their aggression is expressed mostly in the social arena and not as much in their private lives, as they will usually have needed to develop some level of trust with those they are close to. They also tend to separate their emotions: aggression is disconnected from fear, and sex is disconnected from feelings of love and intimacy. The fact that these Sixes regularly move against danger (or perceived danger) can, at times, give them the appearance of a rebel, a daredevil, a risk taker, an adrenaline junkie, or a troublemaker. In some cases, Sexual Sixes may be prone to megalomania or having a "hero complex." In their own way, they seek to be "good guys" to avoid being punished. They may have the illusion that they are spontaneous, but they tend not to be. Sexual Sixes tend to be very contrarian: they always have an argument at hand to refute and contradict an opinion. Instead of thinking in terms of "best-case" or "worst-case" scenarios, they think in terms of contrarian scenarios-if the trend is for others to focus on the worst, they will focus on the best; but if everyone is focusing on the best, they will assert the worst. Although they may seem certain in their assertiveness, Sexual Sixes may hold doubt in their minds for along time-doubting which road to take and so getting caught between choices. They often believe that there is only one truth, and they prefer concrete and pragmatic ideologies because they feel safe and allow control of the world. They fear making an error, and the consequences of doing so. The Sexual Six can look like a Type Eight because both types can appear intimidating, strong, and powerful. However, in contrast to the Eight, who tends to be fearless, the Sexual Six is motivated by an underlying fear, even when they don't consciously feel it of show it. Also, while Eights like to create order, Sexual Sixes often like to disrupt order by stirring up trouble. Sexual Sixes can also look like Threes in that they are action-oriented, fast-moving, assertive, and hardworking. They differ from Threes, however, in that they have more paranoid fantasies and their assertiveness has its basis in fear rather than in the need to achieve and accomplish goals in the service of looking good. Richard, a Sexual Six, speaks: For me the world is a dangerous place and as a result I maintain a constant vigilance. Scanning and looking for inconsistencies in people and the world around me is an ongoing and never-ending task. Dealing with the outside world is exhausting as a result. Social occasions are especially taxing. On a recent night out with my wife, we went to a party where there were twenty to thirty other couples in attendance. Everyone was in a fun and festive mood...including myself. However, I quickly noticed that while my wife was easily approached and engaged by the new people around us, I, on the other hand, seemed to maintain a three-foot "No Fly Zone" around me for at least the first hour. I've realized that my automatic and unconscious approach to dealing with uncertain and potentially threatening situations is to present myself as a potential threat. I don't literally threaten people, of course; it's more of an energy, or an aura, I create around myself without always knowing I'm doing it. I often wonder how others experience me when I'm in that mode, reserved and somewhat stoic, critical and watchful, and physically intense. From the inside, I have the sense that I’m ready to spring into action at a moment's notice. Recently, through therapy, I've realized how important it has been for me to squash fear (and even potential hints of fear) aggressively, assertively, and with prejudice. Specific Work For The Sexual Six on the Path from Vice to VirtueSexual Sixes can travel the path from fear to courage by learning how to be more vulnerable. If you are a Sexual Six, you may at times feel courageous, but don't mistake aggression and "strength" born of fear for real courage. As Naranjo says, the courage of the Sexual Six is the courage of having a weapon. Put down your weapons and learn to tap into your vulnerable emotions as a source of real strength, real power, and real courage. Notice how being strong masks your fear and other vulnerable feelings, and work to get in touch with those instead of always taking refuge in your ability to squash fear and look strong on the outside. Work toward having the courage to be able to let your guard down with more people more often. Allow yourself to feel pleasure without ambivalence and tenderness without reserve. Notice how the fear of losing your freedom and independence may lead you to push people away, and work on learning to trust people more with your more vulnerable feelings. Allow yourself to be guided more by instinct, intuition, and softer emotions so you can expand the ways in which you relate to yourself and open yourself up to others. Recognize that you can be liberated from the fear that keeps you locked inside the hard shell of your "acorn" self by seeing and accepting that you don't always have to be so strong and so vigilant.

[wraithwolf]

so let’s talk about Shieda fucking Kayn——

first off, I actually want to give props to Riot because as much as I change shit around I'm genuinely glad we're continuing to receive lore that intertwines with other pieces rather than having a bunch of standalones that generally fail (and subsequently receive harsher criticism) solely because they have nothing to lean on. as expected some (most) people are unhappy with it but if nothing else I'm glad Kayn has lore beyond his little intro paragraph because y'all know they very well could've just gave us that and left it. (I'm not here to complain about the comm tho that's a separate post) basically, I'm Pleased and there's a lot to think about.

Initially, the decision to make Kayn a Noxian threw me for a Big Ass Loop™ because I was convinced the Order was exclusively for Ionians (more specifically, Ionians proved worthy by Zed) and while Kayn was still chosen by Zed there’s an underlying irony in this choice. We’re deep into the Ionian/Noxian war by the time Kayn is forced into it, and while Zed isn’t exactly the most Merciful or #Relatable person, imagine the intrigue a person such as himself had in seeing a poor, Noxian child with the drive and the anger of that of a seasoned warrior not only still holding on (considering Zed and co. didn’t arrive to the scene for two days after Kayn was dispatched) throughout all of the carnage that surely followed, but finding the strength to take up his weapon once again. For what it’s worth, Kayn was determined to fight for his life or literally die trying no matter who challenged him. We know Kayn didn’t know who was standing over him, but he was willing to fight anyway. I imagine Zed to have found it admirable, but at the same time beneficial: being able to change this boy and harness his rage, then unleash it against the same people that otherwise would’ve let him die at the Epool. The same people that sought to slay his own. I’m 50/50 about this because I speculated Zed had a reason for taking Kayn under his wing, but I didn’t expect the Noxian angle at all.

The thing is, there’s a lot more irony to this beyond Zed taking in a Noxian to use against other Noxians, as we can obviously see. Kayn resembles Zed in many ways— a familiar, stubborn arrogance alongside the same hungry determination that inevitably consumes him to be more than what he is, going as far as to seek an advantage through outside means - just like Zed in seeking out the Box to surpass Shen, Kayn seeks out Rhaast; only it’s safe to say Kayn is far more ambitious in his reasons for doing so, as in Kayn wants control of the fucking Order itself where Zed... wasn’t so bold, at the time.

It’s interesting to think about how an endgame for Kayn (and also Zed, since at least in Zed’s case we have to consider his current (????) involvement with Shen in an attempt to stop Jhin all over again and then add Kayn to the mix) would play out as it is almost entirely dependent on Zed and Kayn’s will alone. Should Kayn succumb to Rhaast, (which now seems a little more plausible with Kayn’s cockiness running amok through everything he does) I imagine the dynamic would change entirely as it goes beyond controlling Kayn as best as Zed can (I use control loosely because while I imagine Zed to run the Order as he sees fit, to make it a total dictatorship still seems like a little bit of a stretch to me if only because we don’t know how Zed reacted to Kayn returning with the Darkin scythe in hand and word that he Literally Killed Nakuri in order to bring it back) to having to deal with him without risking the rest of the Order and all of Ionia itself. They’ve already got Jhin running around, for gods sake, they don’t need a fucking Darkin along with him.

Ultimately, a lot like with champs such as Zed and Jhin, a real endgame is left up to the writer of said character and the overall interpretation itself. The way I see it, Zed isn’t going to be pleased with Kayn’s decisions to not only kill another member of the Order but also to voluntarily give part of himself to Rhaast in order to ‘control’ him; but again we return to Zed’s somewhat Ulterior Motive as to why he brought Kayn in in the first place. It’s not hard to tell that Kayn is confident, though overbearingly so--and from the looks of it, Zed isn’t The Happiest about Kayn’s behavior nor his choices but there are fragments of Kayn that Zed can recall in himself that might just allow certain things... to an extent. I’m in no way saying Zed just “o ok u just killed one of my students and defied my orders and also want The Order from me, Cool” because I’m laughing imagining the lecture/punishment Kayn actually receives after he returns with Rhaast and Kayn just scowling and grumbling the entire time but! I can see him allowing few aspects of Kayn solely because if he can convince Kayn that his strength comes from him, not Rhaast, Kayn can overcome Rhaast, and Zed can continue to shape him.

Also, let me add right now that while I don’t think Zed would risk much for him, (I’ve never supported 100% Evil Zed but I’m not a “Zed Did Nothing Wrong” stan either) I also don’t agree with the idea that Zed wants Kayn to lose himself to Rhaast, that Zed would send Kayn to deal with Jhin, or that Zed would even involve him in it. The risk, in all of these scenarios is vastly higher than the reward. Again, a Literal Darkin running around slaughtering everyone would mean further disaster for Ionia, and inevitably word would get around who brought Kayn (and Rhaast by relation) into the nation, and while Zed isn’t exactly a secret to all, I doubt he’d want to bring himself and his actions front and center. Kayn is still extremely young (eighteen-nineteen??) and while he’s in no way weak or stupid (s/o to Mint for mentioning this entire point to me i love u big hug) Jhin has years of experience on him. It wouldn’t be difficult for Jhin to take advantage of Kayn and either kill him on the spot or put him through worse knowing it was a stronger way to get to Zed especially if we can assume Kayn would completely underestimate him. For what it’s worth... my interpretation, specifically, has yet to know of Jhin at all. Whether or not he later on learns and what happens thereafter is to be decided. (*aggressively chinhands*)

Furthermore, in regards to the “wow he is so cliche” “wow he is so edgy” arguments that plague his Entire Fucking Existence and tag right now... yes. It was obvious he was going to be a little edgy and a little bit of a cliche. That doesn’t (and it shouldn’t) take away from the potential he has to further flesh out the lore as a whole. You gotta realize now more than ever that Kayn is young, one of the youngest champions (?) to have a fairly deep involvement with some larger scale issues going on within the overall story. I can name a few other champs that follow a similar path and are edgy in their own respects, but I’m not going to. The lore has disproved many things, one of them being that Kayn isn’t Just Edgy for the sake of being edgy. It’s very likely that as he grows and matures, a lot of his current mannerisms will fade/vanish entirely depending on what happens to him in the future. In a nutshell, being edgy doesn’t make him a joke, and he’s clearly not an unconditional, rampant Zed fanboi uguu kouhai xDdD like a lot of people were using at the forefront of their argument as to why they dislike him. 💁

TO CONCLUDE ... I like Kayn, I like his lore, and I’m really liking the possibilities for building him and taking him in a direction entirely my own. (and that’s just for main verse, let alone the possible skin aus, modern verse, what have you) Of course, it wouldn’t be a Blog by Hina™ without some divergence, but I’ll be figuring that out as I go. I already have some specific ideas pertaining to my interpretation exclusively, but they need to be tested/written down before I can really apply them. I am Happy, and I’m looking forward to keeping this going.

some additional stuff I noted/had confirmed to cover later but still want to mention:

nakuri calls kayn brother! the order is (at least somewhat) familial! miss me with that ‘nobody cares abt each other in the order’ shit

is it safe to say kayn’s abilities covered in the lore/in game (the wall walking and the ability to literally enter bodies for a short time especially) are things zed is also capable of? he couldn’t have learned them from anyone but zed, right?

A Big Old Confirmation that when kayn enters another body, he can see (and subsequently feel) just as the person would be for that moment. i’d like to think that eventually, kayn can fine tune this ability and utilize it for longer durations, however i imagine there will always be a risk from it and the victim will most likely always suffer afterwards. more on that Eventually™

another Big Confirm that rhaast’s control leaves both physical and mental effects on the body (however it happens a lot faster than i originally anticipated) and the longer the usage, the more this shows in the form of carapace. i’ll also be covering this at Some Point but even in kayn’s shadow assassin form, we see that the carapace is Gone (?) but in its place are dark dark marks, implying that even once rhaast is purged, remnants of him are still there most likely because of how long he was allowed to manifest. i’m still debating if this actually would hinder kayn’s eyesight / usage of his arm for a while should he overcome rhaast.

rhaast can be heard by more than just his wielder, which is something i wasn’t thinking was possible. however, this could be a conditional thing to where either rhaast can choose who hears him or the only ones that do hear him are those susceptible to his control. either? or? the world is yet to know.

[alltheselights]

Vampire Fic Snippet #3

(And the last one before the fic is posted!!!!!!!!! yay, sorry this is taking ages)

As always, I want to note that this is from the draft of the fic, so some things may be changed for the final version.

Warning: Mentions of vampire biting and so on, but still nothing graphic.

There’s a smudge of blood on his collar, likely from his earlier snack of the night, and for a moment, Louis allows himself to entertain a lovely fantasy in which he punches this vampire’s stupid looking face and doesn’t break his hand.

“You’re so beautiful that it hurts to look at you, honestly,” the vampire says, smirking.

“Then close your eyes,” Louis replies, voice sugary sweet.

The vampire chuckles darkly, clearly undeterred by Louis’ rudeness.

“Kitten has claws, I see,” he says, stepping further into Louis’ personal space. Louis rolls his eyes.

“Yes, kitten does,” he says, choosing that moment to blow smoke from his cigarette into the guy’s face. “And kitten is going to claw your eyes out if you don’t step the fuck back right this second."

The vampire’s eyes flash red with anger and he opens his mouth to respond, but before he gets the chance, Louis hears the sound of the door opening. Both he and the prick standing in front of him refocus their attention on whoever has stepped out onto the balcony, and Louis can’t help but roll his eyes again when he sees who’s joined them.

“Hi, gentlemen,” Harry says, voice slow and deep. He has a small smile on his face and he looks perfectly serene, but Louis has the feeling that he knows exactly what he was interrupting.

Louis takes the momentary distraction as an opportunity to shove the vampire away from him, and though he glares at Louis when he stumbles back slightly, caught off guard, he doesn’t bother trying to get back into Louis’ personal space. Instead, the vampire turns and walks toward the door, roughly shouldering past Harry despite there being plenty of room to avoid him. Louis knows that if the vampire had chosen to sideswipe him on his way past, he’d probably have been knocked off balance enough that he would fall to the ground. Harry doesn’t move a muscle, however, and he even keeps the calm smile on his face as though he felt nothing more than the fluttering of the breeze.  

When the door closes, Harry and Louis are alone. Louis shivers slightly and tells himself it’s because of the air temperature.

Harry takes a few cautious steps forward.

“Are you gonna claw me if I try to give you my jacket, wildcat?” Harry asks, smile in his voice. Without waiting for an answer, he shrugs out of the jacket and holds it out to Louis as an offering.

Louis sighs and takes it, grumbling out a “thank you” under his breath. The jacket is warm and it smells like Harry’s cologne, and Louis would like to be able to say that he’s disgusted by the scent, but he’s really, really not.

He sighs and turns back to the balcony railing, taking the last couple of puffs from his cigarette. Harry approaches slowly, eventually moving to lean against the balcony beside Louis, leaving just a couple of inches between their bodies.

“Seems like you have a knack for attracting trouble,” Harry says, tone light as he gazes out over the city.

Louis flicks his cigarette and watches the ash fall until it’s no longer visible in the darkness of the alley below.

“More accurately, I’d say that I have a knack for attracting assholes,” Louis says, even as he shivers and burrows himself deeper into Harry’s jacket.

“Oh yeah?” Harry asks. He sounds amused, but he’s not bothering to look at Louis, still keeping his gaze on the view.

Louis feels like he’s being baited. He doesn’t like it one bit.

“You’re here, aren’t you?” Louis mocks, flicking away the butt of his cigarette and taking a step back from the balcony. It’s time to put as much distance between himself and Harry as possible, and besides, he needs another three shots of tequila stat.

Louis is about halfway to the door when Harry’s hand catches on his elbow, spinning him around so quickly that he doesn’t even realize what’s happening until he’s face to face with the vampire. They’re much closer together than Louis anticipated, and Louis can see every speck of green and gold in Harry’s eyes.

He can also see that Harry’s gaze is on his mouth.

“You almost forgot your lighter,” Harry says quietly, holding the lighter out from where he must have snatched it off the balcony railing. His other hand moves from Louis’ elbow to his waist, and though his grip isn’t tight, Louis is startled by how possessive the gesture feels.

“Thanks,” Louis says quietly, little more than an exhale of breath. For some reason, he can’t bring himself to make the word sound sarcastic or mocking. Louis doesn’t reach out to take the lighter.

They just stand there for a moment, gazing at each other without speaking. Finally, Harry puts the lighter in the pocket of his coat without bothering to look away from Louis’ face. When Louis licks his lips, Harry’s eyes track the movement.

Louis’ body is vibrating with anticipation. He knows he should move out of Harry’s grip, spin on his heels, and retreat back inside, forget this entire interaction even happened. Harry would let him, Louis thinks. He’s the cockiest bastard Louis has met in a while, but somewhere deep in his bones, some instinctual understanding of Harry tells him that he would let Louis walk away and never speak about this moment again. If that was what he wanted.

Harry tightens his grip on Louis’ waist slightly and brings his other hand up to cup Louis’ chin. He thumbs over Louis’ cheek gently, and Louis closes his eyes at the touch. Harry’s hands are cool and soft, and if Louis hadn’t been staring him in the face a few seconds earlier, Louis would never be able to guess that it’s a vampire touching him this way. Touching him as though he’s made of the most fragile glass.

“Did I mention that you have the most beautiful face I’ve ever seen?” Harry asks, and Louis’ eyes fly open, brows furrowing into a glare. Harry has a huge smile on his face, dimples prominent, and Louis wants to knee him in the balls.

Instead, he surges up onto his toes and kisses Harry on the mouth. Their teeth clink together at the force of it, but Harry’s hand on Louis’ jaw guides their lips together properly, slowing Louis down and turning the kiss into something different than he intended — something less aggressive and urgent, more sensual and overwhelming.

“Shut up,” Louis gasps out, pulling back just enough to say the words against Harry’s lips before moving into the kiss again, and he feels the press of Harry’s answering grin against his mouth. Louis moves one of his hands to Harry’s hair, threading his fingers through the wild curls there, tugging slightly, and it has the effect he intended. Harry groans against Louis’ mouth and before Louis even has the chance to take another half breath, Harry’s closed the ten feet of distance between them and the building. Louis feels his back hit the brick wall.

“Fuck,” he says, and when Harry makes a considering sound at the word, Louis doesn’t even bother pretending that he’s annoyed. There’s also a complaint on the top of Louis’ tongue about being manhandled against the wall using vampire speed and strength, but he swallows it. Harry would know he was lying about hating it anyway.

Harry moves his hands all over Louis’ body while they kiss, and if Louis weren’t half out of his mind with desire already, he’d probably be embarrassed by the fact that Harry’s touch is raising a trail of goosebumps across his skin.

When Harry moves his lips down to kiss along Louis’ jaw, Louis takes the opportunity to catch his breath. Embarrassingly enough, Louis’ chest is heaving and his heartbeat is moving at triple its regular speed. He doesn’t understand why kissing is affecting him like this, but he dismisses it as the result of not having gotten laid in a while.

Harry mouths his way down Louis’ neck, breathing hotly and sucking intermittently, probably leaving a smattering of red marks in his wake. His fangs still aren’t out though, and Louis can’t help the frustration bubbling in his chest.

“Can you, uh, fuck,” Louis says, cutting himself off as Harry sucks a bruise at his pulse point.

“Can I what?” Harry asks, standing up straight again so he can look Louis in the eyes. His cocky tone is back, and Louis tells himself that he didn’t miss it one bit. He tries to ignore the throbbing feeling in his groin.

“What do you want me to do?” Harry asks again, eyes dark. Louis breathes heavily, but doesn’t say anything.

“This?” Harry asks, pushing his leg between Louis’ and pressing against his erection. Louis gasps slightly at finally being touched there, even if it’s not the way he really wants. They’ve only been making out for a few minutes, probably, but Louis feels like he’s been hard for ages.

He bites his lip and still doesn’t answer Harry, which only makes the vampire’s smile grow.

“Or…this?” Harry touches his cool fingertips to the side of Louis’ neck, pressing hard at the bruise already there.

Louis moves one of his hands to the front of Harry’s pants, cupping his erection firmly, hoping to distract Harry enough that he’ll give Louis what he wants. Harry’s eyes fall closed briefly with pleasure at the feeling, but he gains control of himself quickly, taking Louis’ hand and moving it to his hip, a safe enough distance away from his cock.

“I’m not going to do anything until you tell me what you want,” Harry says, and he still sounds arrogant as hell, but there’s a seriousness underlying his tone that makes Louis’ gut clench.

Louis pushes forward to kiss Harry again, their tongues intertwining briefly before Louis retreats enough to run his tongue along Harry’s bottom lip. “Bite me,” Louis finally says, focusing his eyes on Harry’s even though there’s only about an inch between their faces, making the gaze more intense. He speaks quietly enough that his words are barely even legible to his own ears, but Harry can hear him perfectly.

Louis is still being pressed into the wall, so he lets his head fall backwards. There’s a slight jolt of pain when the back of his skull makes contact with the brick, but the pain of it is a welcome distraction. It give him something to focus on — something besides the desire overwhelming his senses when Harry finally, finally, finally allows his fangs to descend.

[cashcounts]

Will Surgery and Anesthesia Harm Your Memory?

Dr. H. had a struggling heart and a consequential decision to make. He needed an operation to fix a faulty valve but postponed it, afraid that the surgery and anesthesia would irrevocably damage his brain. The man made this decision more than a decade ago based on a phenomenon that was reported in an alarming article all the way back in 1955—one that many doctors still see first hand—of older patients who deteriorate cognitively after surgery.

“When patients are asked, ‘what is the thing that you fear the most?’ it’s being disabled,” says Mervyn Maze, an anesthesiologist and researcher at the University of San Francisco. “It’s not dying. It’s living with a cognitive disability. And that becomes even more scary the older that you get.”

PET scans show profound changes in the brain’s immune response three months after major abdominal surgery.

The author of the 1955 The Lancet article was a surgeon and consulting physician in England who reviewed thousands of charts and zeroed in on 18 “extreme” cases of people who appeared to be cognitively normal before the operation but became severely demented afterwards. He concluded that “operations on elderly people should be confined to unequivocally necessary cases.”

It was a bold statement, and one that likely overstated the risk. Today, you would be unlikely to find a surgeon who would advise against surgery that could significantly improve your quality of life. But the potential for damage remains. Dallas Seitz is a young geriatric psychiatrist at Queen’s University in Ontario, Canada, who says his colleagues are familiar with memory or cognitive problems after surgery, what’s been known as postoperative cognitive dysfunction, or POCD. “I would be hard pressed to find a colleague who said I’ve never heard of it or I don’t think that that exists,” he says, though he’s quick to acknowledge that such anecdotes are not scientific evidence. “It’s not an experimental study. But I think we can’t discount what our patients tell us and what our experience tells us as well.”

A patient undergoes cardiac surgery.

Because some 60,000 people a year undergo surgery in the U.S., and the numbers continue to climb, quantifying the risk is essential. It hasn’t helped that the term “POCD” is vague. “We’re talking about things that happen immediately after operations, like delirium, to things that happen perhaps a decade after an operation like dementia or Alzheimer’s,” notes Roderic Eckenhoff, an anesthesiologist and researcher at the University of Pennsylvania. New, more precise terms will soon be announced, and even though the picture is muddled, there is hope that the tools of modern science—from animal models to well-designed clinical trials—will bring more clarity.

Delirium is the most likely complication of surgery in older adults, with a risk as high as 60%. Patients with delirium are in a temporary and sometimes fluctuating type of acute brain failure: they can be confused, sometimes hallucinatory, aggressive, agitated, or sleepy and passive. Some small subset have mild cognitive impairment that can last for months before they recover. Their memory is not as clear and they describe themselves as being in a fog. They are generally less competent at planning or making decisions. And, worryingly, some remain permanently impaired or even descend into dementia, with studies suggesting that this outcome is more likely in patients who experience delirium compared to those who don’t.

But it turns out that many older people were already on the road to dementia before their surgery. “It’s a standard sort of thing that we hear, that we are contacted by people who say, ‘you know, Mom was perfectly fine or Dad was perfectly fine until they had their knee replacement,’ says Lis Evered, an anesthesiologist and researcher at St. Vincent’s Hospital Melbourne in Australia. “But when you drill down on the ‘perfectly fine,’ they weren’t perfectly fine. It’s just that they were coping. And people develop strategies that can cover a decline quite markedly.”

Between 10–34% percent of people over the age of 65 are already in a state of mental decline ranging from mild cognitive impairment—problems that go beyond what you would expect in normal aging—to dementia, including the most common form, Alzheimer’s disease. Evaluating someone’s mental status can be tricky, and not just because they’ve developed coping strategies. A visit to the surgeon before the operation occurs at a particular moment in time, but patients have good and bad days, and cognitive decline doesn’t always follow a smooth trajectory. It’s only after surgery that an underlying vulnerability may be unmasked. A recent study published in The Neurobiology of Aging showed that in apparently normal adults undergoing elective surgery with general anesthesia, a particular brain signature associated with the development of Alzheimer’s disease was tied to how severe the postoperative delirium was.

Go behind the scenes of major clinical drug trials in the documentary, “Can Alzheimer’s Be Stopped?“

“Patients are saying, ‘look this is my husband, he has cognitive impairment, and I’m really worried about conversion to Alzheimer’s,’” says Dr. Charles Brown, a cardiac anesthesiologist and researcher at Johns Hopkins University, “‘How does this particular procedure affect that? Should I get it? Should I not? If I do get it, how are you going to manage me differently?’ “

Quantifying the Risk

“It’s very important to really be careful about what we know, about what we don’t know, and what we anticipate or hypothesize,” cautions Lars Eriksson, an anesthesiologist and clinical researcher at Karolinska University Hospital in Sweden. Many studies have significant weaknesses, adds Michael Avidan, an anesthesiologist and researcher at Washington University in St. Louis, and that includes overlooking shared risk factors.

“If you have a cohort of people who have a disease that is known to be associated with cognitive decline,” Avidan says, “like hypertension, people who are heavy smokers, who are obese, who have diabetes, who have peripheral vascular disease, who have arthritis—whether or not they undergo surgery I can predict that those people are going to decline cognitively more than people who are marathon runners who are fit and all the rest of it.” Moreover, hospitalization itself, with or without surgery, has been shown to be a risk factor for cognitive decline, for reasons that are not entirely clear.

Avidan believes the evidence for the idea that anesthesia and surgery cause long term cognitive decline is “incredibly flimsy,” and points to a 2013 randomized controlled clinical trial published in The Annals of Thoracic Surgery as strong support for the idea that the risk is overblown, or perhaps even non-existent. The study found that patients who had open heart coronary artery bypass surgery with general anesthesia were better off cognitively 7.5 years after surgery than those who were treated with a less invasive non-surgical procedure that used only regional anesthesia. (Because regional or local anesthesia does not enter the brain, it’s assumed that it has no impact on brain function.)

In contrast, a 2017 study in Alzheimer Disease and Associated Disorders reached the opposite conclusion, finding an association between coronary artery bypass graft surgery and long-term dementia risk. The researchers controlled for many typical risk factors but was not randomized.

These are just two studies out of hundreds of others published over the past decade, each with different groups of patients or types of operations. That makes it difficult to reach a definitive conclusion on whether surgery and anesthesia cause permanent cognitive decline.

Managing the Immune Response

Perhaps it shouldn’t be so surprising that some elderly patients experience profound changes to their mental capacities after an operation. Surgery is a violent assault on the whole body, of which the brain is a part. Anesthesiologists administer drugs that push the brain into a reversible state of amnesia, immobility, loss of consciousness, and freedom from pain. Surgeons cut open bodies, stop hearts, replace hips or knees with titanium, and stitch stomachs smaller and tighter. In response, the traumatized tissues release substances that engage the immune system, activating a host of key cells and proteins that encourage healing. A mere 12 hours after surgery, signs of inflammation can also be detected in the cerebrospinal fluid. This is actually a good thing.

“There is a signal within the body after peripheral injury that’s purposeful, that reaches the brain,” Eriksson says. “And that contributes to a condition that you could call sickness behavior, or the injured phenotype. It’s time to rest—to not be out hunting for food—and to heal. But, of course, when the injury becomes so large and big and it goes over the top, the situation can be different.”

An immune response that doesn’t know when to quit is likely to be dangerous. In the elderly, the blood brain barrier is weaker, giving immune cells easier access to the brain. In aged rodents, scientists have found inflammatory molecules crossing the blood brain barrier and setting up shop in areas that are essential for learning and memory, such as the hippocampus. In human patients, researchers also found amyloid beta and tau—two proteins associated with Alzheimer’s disease—went from normal levels before cardiac surgery to levels associated with mild cognitive impairment six months after the operation. Other studies have shown similar changes as soon as 48 hours after surgery.

This year, an international study by Eriksson and his colleagues pulled off a pioneering feat—using PET scans to image the immune response in patients before surgery, three to four days afterwards, and again at three months. In four of the eight patients, they saw profound and global changes in the brain’s immune system three months after surgery, long after the patients were home and going about their daily lives.“There was an association between the amount of immune activity and the decline in cognitive capacity,” Ericsson says. “The more unregulated your immune system was at three months, the worse was the cognitive function.”

But finding a way to safely and effectively intervene in the immune response is notoriously difficult. In the case of surgical patients, extinguishing the initial inflammation could disrupt important processes like wound healing. “I suppose until we actually understand the mechanisms that are occurring in the perioperative period, trying to address what interventions might have an impact is very difficult,” says Evered, the Melbourne-based anesthesiologist. Many experts underscore the importance of using animal models to suggest possible mechanisms for the disease process so as to develop treatments. But a key interim step is to make sure that that same mechanism translates in humans. This is what makes Eriksson’s recent PET imaging study so important—it makes the connection between what we see in rodent models and what we see in us.

Optimizing Anesthesia

Regardless of the actual mechanism, doctors and researchers are hard at work to find anesthetics and postoperative practices that will minimize the risk of any sort of cognitive decline. “If you are going to have a procedure, what are the ways that we can protect the brain the most?” asks Dr. Brown, who is investigating whether optimizing blood flow to the brain during surgery can make a difference. “Maybe you’re someone with mild cognitive impairment—and that is such a strong predictor of further cognitive decline—maybe you need to take that into account a lot more.”

Optimizing anesthesia could be one way to mitigate risk. Anesthesia was the original leading contender for cognitive decline, but while studies in rodents have shown toxic effects, the data for human trials has not. In a 2014 study of more than 12,000 patients, Dallas Seitz from Ontario found that the risk of dementia in patients who had an operation under general anesthesia versus regional, or local pain control, was “almost identical in the two groups. There was no statistical difference.” This is but one of many studies that lead anesthesiologists like Eckenhoff to believe that “the anesthetic is a minor player.”

This anesthesia monitor combines EEG brain wave monitoring with other measurements such as heart rate.

While we don’t know if anesthesia can hurt the human brain, what if certain types of anesthetic drugs could help protect it? Until recently, investigating this idea has been hamstrung by the simple fact that it would be unethical to perform surgery—whether on people or lab animals—without any anesthesia. But a discovery by Maze and colleagues provided a neat workaround. They showed that a protein called HMGB1, which launches the immune response to trauma, can simulate the inflammatory effect of surgery. “We now don’t have to do surgery to cause the surgical effect,” Maze says. “We can just provide an injection of HMGB1 and start the process that way.” Maze is a co-founder of a start-up company called NeuroproteXeon that is in a phase 3 clinical trial of xenon. Xenon is not the only drug or class of drugs being investigated for neuroprotective qualities. For example, in small clinical trials, the anesthetic agent ketamine has been shown to reduce postoperative cognitive impairments, perhaps by modulating the immune response.

Another way to optimize anesthesia could be to fine-tune the amount a patient receives. Typically anesthesiologists track heart rate and blood pressure as their guide for deciding whether the patient has the right amount of drugs on board. But Avidan and others are investigating whether monitoring brain waves during surgery using an EEG can identify a “goldilocks” amount of general anesthesia that could decrease the risk of delirium. It’s easy to give more drugs than necessary, particularly in the elderly. “We’re trying to prevent or to avoid a pattern called EEG suppression during general anesthesia, where the EEG looks like it’s flatlined, and to see if that decreases postoperative delirium,” says Avidan.

Optimizing Patient Care

Other measures could include making sure sleep and nutrition are optimal and that patients are given the right antibiotics at the right time to decrease the likelihood of surgical wound infections.

And then there’s a decidedly low-tech approach: reorienting patients quickly. This includes having friends or family nearby as soon as possible after the operation, giving back their glasses, dentures, and hearing aids, or putting clocks and calendars on the wall. While it’s unproven whether this reduces delirium, “there’s no downside to doing these things,” Avidan says. “And it’s kind. If nothing else it’s respecting people’s humanity and dignity, and making their surgery experience more pleasant. So you have enough reason to do that regardless of whether or not you think it’ll improve short or long term outcomes.“

None of these approaches are likely to tackle the problem on their own, though. Robert Whittington, an anesthesiologist and researcher at Columbia University Medical Center, addressed this question at the 2017 meeting of the American Society of Anesthesiologists, pointing out that given the complexity of the brain, rather than trying to find the magic bullet therapy, there should be a multi-pronged approach similar to treatment strategies for HIV.

As with many medical procedures, and as with Dr. H., who chose not to get heart surgery, making tough decisions goes back to looking at risk and benefit. Surgery is a powerful stress test that can unmask underlying cognitive problems. But by the same token, surgeries that repair your heart or your hip, that allow you to exercise, or that reduce pain can improve your cognition.

Older people should be aware that their brains may still be healing long after they go home. But there is still an unanswered question: can surgery and anesthesia accelerate or even cause a permanent cognitive decline, even if the surgery and aftercare are optimal? On top of all the vulnerabilities that elderly patients may enter the operating room with—from previous risk factors for cognitive decline, to leaky blood brain barriers, to the mere fact of being in a hospital—is there a specific surgical vulnerability for permanent cognitive decline that has yet to be nailed down?

“There can be a little subgroup, perhaps not very big, that has a very unfavorable outcome,” says Eriksson. “And if you don’t do standard studies, using standard designs, those people may go undetected. The biological signal might be very small. There might be vulnerable individuals out there where a particular trigger—in this case surgery—where the pathways are very important. We might not be able to detect them. There could be vulnerability out there that we need to define.”