Your Questions About
Brain Health & Surgery

The NSRI™ is the first validated pre-surgical assessment tool designed to measure the brain’s capacity to absorb and recover from neurologic stressors — including anesthesia and surgery. Think of it as a stress test for your brain.

It scores your neurologic reserve across five modifiable domains — Cardiometabolic Health, Medication & Pain Burden, Sleep & Circadian Health, Lifestyle, and Brain & Social Health — and calculates a Bottleneck Index™ based on your historical vulnerability factors. Together, these produce a single composite score (0–100) and a personalized report.

Developed by Sandra Bargeron, PA-C, CAA — a Certified Anesthesiologist Assistant with 22 years of clinical experience and 10,000+ anesthesia cases. Supported by 75+ peer-reviewed references.

The NSRI™ measures two things: reserve (how much neurologic stress your brain can absorb before function degrades) and recovery (how quickly and completely your brain returns to baseline after stress exposure).

Specifically it scores five domains: your cardiovascular and metabolic health, your medication and chronic pain burden, the quality and architecture of your sleep, your lifestyle factors (exercise, hydration, nutrition), and your brain and social health factors. It also captures historical vulnerabilities through 11 history sections — things like prior head injuries, previous surgical delirium, and cumulative anesthesia exposure.

What makes it different from general brain health tools: it was designed specifically for the pre-surgical context — measuring what determines outcomes when the brain faces an acute neurologic stress event, not just day-to-day function.

Standard preoperative screening checks your heart, lungs, kidneys, and blood. It does not measure whether your brain has the neurologic reserve to handle anesthesia and surgery — or recover from it. That gap has existed in medicine for decades.

The NSRI™ is the first tool built specifically to fill it. It measures the modifiable factors that determine how your brain handles a surgical stress event — in 15–20 minutes, from home, with no lab work required.

The Bottleneck Index™ captures the historical and biological factors that constrain your brain’s recovery capacity — even when your current lifestyle scores are strong. It includes things like prior head injuries, previous surgical delirium, family history of dementia, prior anesthesia reactions, and cumulative anesthesia exposure.

These factors don’t disappear because you started exercising or sleeping better. But knowing they’re present changes how aggressively you prepare — and what you tell your care team.

98.4% of NSRI™ completers carry at least one Bottleneck factor. Most had no idea. The Bottleneck Index™ is applied as a multiplicative adjustment to your base score, so the final number reflects your complete picture — not just your modifiable factors in isolation.

HARP™ — Holistic Anesthesia Recovery & Preparation — is the first clinical application framework built on the NSRI™ platform. It translates NSRI™ findings into a four-step action structure:

H — Health Assessment (measure with the NSRI™)  ·  A — Address Daily Exposures (reduce modifiable neurologic burden)  ·  R — Resilience Building (strengthen depleted domains)  ·  P — Post-Surgical Protection (support brain recovery after surgery)

HARP™ is a framework, not a protocol. It guides the direction of optimization without being prescriptive.

Yes. The NSRI™ is supported by 75+ peer-reviewed references organized across its five scored domains and history sections. All references are verified via PubMed or primary source. Key foundational literature includes:

Lancet Commissions on Dementia (2017, 2020, 2024) · Evered et al. 2018 (POCD nomenclature) · Inouye et al. 2014 (delirium) · Gray et al. 2015 (anticholinergic dementia risk) · Billioti de Gage et al. 2014 (benzodiazepines and Alzheimer’s risk) · Fried et al. 2001 (frailty phenotype)

The complete verified reference library is available at beyondbrainhealth.com/nsri-evidence.

Post-surgical brain fog — clinically called Postoperative Cognitive Dysfunction (POCD) or, per the 2018 Evered nomenclature, Delayed Neurocognitive Recovery — occurs when the brain lacks sufficient neurologic reserve to handle the combined stress of anesthesia, surgery, inflammation, and recovery.

Key risk factors include: poor sleep quality, sedentary lifestyle, anticholinergic medication burden, uncontrolled metabolic conditions (blood pressure, blood sugar, cholesterol), prior head injuries, family history of dementia, and cumulative anesthesia exposure. Most people carry several of these without knowing it.

These factors are measurable. Many are modifiable before surgery. That’s exactly what the NSRI™ was built to identify.

Research shows that in individuals with depleted neurologic reserve, anesthesia and surgery can accelerate cognitive decline — but this is not inevitable or universal. The outcome depends significantly on the brain’s pre-existing state going into the procedure.

Risk is substantially higher in people who carry: prior head injury history, family history of dementia, high anticholinergic drug burden, poor sleep, sedentary lifestyle, uncontrolled metabolic factors, or prior delirium episodes. These are all factors the NSRI™ measures.

The empowerment framing matters here: we don’t predict who will decline. We identify what can be strengthened before the surgical event occurs.

Brain protection before surgery is most effective when it’s specific to your actual depletion pattern — not generic advice. That’s exactly what the NSRI™ is designed to produce. But the five domain areas to address are:

Cardiometabolic: get blood pressure, blood sugar, and cholesterol as well-controlled as possible. Cholesterol variability is an underrecognized brain risk.

Medication burden: review your medications for anticholinergic load and CNS-active drugs with your prescriber. Many common medications — sleep aids, allergy drugs, bladder medications — carry brain burden most people aren’t aware of.

Sleep: address fragmented or non-restorative sleep. Get screened for sleep apnea if you snore or wake unrefreshed. Only 9.4% of NSRI™ completers report truly restorative sleep.

Lifestyle: even modest increases in physical activity and hydration before surgery have measurable effects on cognitive recovery. 38% of completers rarely or never exercise.

Brain and social health: stay cognitively and socially engaged in the weeks before your procedure. Isolation and disengagement are measurable brain reserve depleters.

Standard preoperative screening was designed to assess surgical and anesthetic risk for the body — cardiac clearance, pulmonary function, kidney function, bleeding risk. It was never designed to measure neurologic reserve or brain resilience before a stress event.

The perioperative brain health field is relatively young. The landmark nomenclature consensus for POCD was only published in 2018. The Lancet Commission on Dementia didn’t quantify the 14 modifiable risk factors until 2024. The clinical tools to act on this science at the individual patient level — like the NSRI™ — are just now being built.

This is not a criticism of medicine. It’s a gap in the system that is actively being closed — and that patients can act on now, before their procedure.

The NSRI™ uses a hybrid scoring model. The five modifiable domains produce a base score out of 100. That score is then adjusted by the Bottleneck Index™ using the formula: Final Score = Base Score × (1 − 0.35 × Bottleneck Index).

The Bottleneck Index runs from 0 to 1. A Bottleneck Index of 0 means no historical penalty. A Bottleneck Index of 1 would apply the maximum 35% reduction. Most completers land between 0.2 and 0.5 — the mean across 869+ completers is 0.292.

This design reflects a clinical reality: historical factors matter and can’t be erased by lifestyle changes alone. But they also don’t override everything — strong domain scores still move the needle meaningfully.

Strong (81–100): Well-optimized neurologic reserve. Your brain is in a good position to handle surgical stress. Continue what you’re doing and address any specific domain gaps identified in your report.

Moderate (61–80): Some depletion in one or more domains. Targeted optimization is available and meaningful. This is where 53.3% of completers land.

Low (41–60): Significant neuro-resilience depletion. Intervention is recommended before any surgical event. 27.2% of completers score here.

Critical (0–40): Immediate optimization recommended. Your neurologic reserve is significantly compromised going into a surgical stress event. 5% of completers score here. This group has the highest urgency and the highest opportunity.

A Low or Critical score means your neurologic reserve is significantly depleted going into a surgical stress event. It does not predict cognitive decline. It identifies the specific factors that, if addressed, would meaningfully improve your brain’s capacity to handle and recover from surgery.

32.3% of completers scored Low or Critical — and most had no idea. The report gives you exactly what to focus on, organized by impact, with care team language you can bring to your provider.

A lower score means more urgency and more opportunity — not a verdict.

Across 869+ completers as of March 2026, the mean final NSRI™ score is 65.8 out of 100 — placing the average completer in the Moderate range. The mean Bottleneck Index is 0.292.

Score distribution: 14.5% Strong · 53.3% Moderate · 27.2% Low · 5.0% Critical. The weakest scored domains are D4 Lifestyle (76.3% of max) and D3 Sleep (76.4% of max). The most common modifiable vulnerability is exercise frequency — 38% of completers rarely or never exercise.

15–20 minutes for most completers. No lab work. No clinic visit. You can take it from home. The questions are straightforward — no medical jargon required. You’ll recognize everything you’re asked about.

Your personalized report is delivered immediately upon completion.

Your NSRI™ report includes: your overall composite score (0–100), a domain-by-domain breakdown across all five scored areas, your Bottleneck Index™ and which historical factors are contributing, a ranked list of your most modifiable priority areas, specific next-step recommendations matched to your results, and care team language you can bring directly to your surgeon or anesthesiologist.

The report is designed to be useful — not just informative. It tells you what to do with what you find, not just what you found.

Anyone who will have surgery — not just high-risk patients. The data shows most people don’t know their neurologic risk until surgery reveals it. The NSRI™ was designed for the general pre-surgical population.

It’s also valuable for people proactively optimizing brain health without a surgery scheduled, caregivers advocating for someone heading into a procedure, and functional or integrative medicine practitioners who want measurement infrastructure for perioperative brain optimization.

The NSRI™ is currently designed for adults. A pediatric adaptation is in development.

No. The NSRI™ is not a replacement for standard preoperative medical evaluation or your care team’s clinical judgment. It does not diagnose any condition or prescribe any treatment.

Think of it as information you bring to your pre-op appointment — not a substitute for it. It gives your surgeon, anesthesiologist, or integrative practitioner a layer of neurologic context that standard pre-op screening doesn’t provide.

The NSRI™ is currently free during the research window, which closes March 12, 2026. After that, standard pricing apply at $97.

If you’re reading this before March 12 — take it now. Take the NSRI™ free →

Sandra Bargeron, PA-C, CAA is a licensed Physician Assistant and Certified Anesthesiologist Assistant with 22 years of clinical experience and 10,000+ personally administered anesthesia cases. She spent 16 years at the head of the operating table — and watched patients emerge from surgery cognitively changed in ways that standard pre-op screening never predicted and that medicine rarely addressed afterward.

She built the NSRI™ from inside the specialty, not outside it. Her CAA credential is the source of authority here — this is an insider’s observation about a gap in patient safety, not an outsider’s critique of medicine.

She is also the author of Break Through Anesthesia Fog (April 2026) and host of the ReThink It: The Brain Health & Longevity Podcast. Read more about Sandra →

A Certified Anesthesiologist Assistant (CAA) is a highly trained anesthesia specialist who works under the medical direction of a physician anesthesiologist to deliver anesthesia care. The credential requires a master’s-level graduate degree and national board certification.

CAAs have direct hands-on responsibility for airway management, anesthetic drug selection and delivery, patient monitoring, and perioperative care. Sandra’s 16 years as a CAA with 10,000+ cases gives her direct clinical authority on what happens to the brain under anesthesia — and what standard screening misses before a patient ever reaches the OR.

Break Through Anesthesia Fog (April 2026) is the first book to connect neuroinflammation, hormonal shifts, methylation, and gut health to how the brain handles anesthesia and surgical recovery. It’s written for patients, caregivers, and practitioners who want a complete picture — not just “you should be fine.”

Available at Amazon and wherever books are sold.