POSTOPERATIVE COGNITIVE DYSFUNCTION

What should we know?

Siti Chasnak SalehAirlangga Univ./Soetomo Hospt.

Surabaya

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Characterization of POCDMemory impairment as identified by a reduced ability to learn or recall information.Disturbance in executive functioning Disturbance in attention or speed of information processingImpairment of perceptual-motor abilitiesImpairment in language

GERIATRIC & AGING 2003;vol 6 no 10

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POCD

• Not detected until days or weeks after anesthesia.• Duration of several weeks to permanent• Diagnosis is only warranted if: - corroborated with neurophychological testing - evidence of greater memory loss than one would expect due to normal aging

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Long-term postoperative cognitive dysfunctionin the elderly: ISPOCD1 study

JT Moller P Cluitmans LS Rasmussen P Houx H Rasmussen J CanetJT Moller P Cluitmans LS Rasmussen P Houx H Rasmussen J CanetP Rabbitt J Jolles K Larsen CD Hanning O Langeron T Johnson PM LauvenP Rabbitt J Jolles K Larsen CD Hanning O Langeron T Johnson PM Lauven

PA Kristensen A Biedler H van Beem O Fraidakis, JH SilversteinPA Kristensen A Biedler H van Beem O Fraidakis, JH SilversteinJEW Beneken JS Gravenstein for the ISPOCD investigatorsJEW Beneken JS Gravenstein for the ISPOCD investigators

THE LANCET 1998;351:857-861

• Collaborative research effort:– Members from 8 European countries and USA– 13 hospitals

• Research conducted from 1994 - 1996

International Study of Postoperative Cognitive Dysfunction

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30Pe

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Early Late

ControlsPatients

Lancet 1998: 351-357

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* p < 0.004

Incidence of POCD in patients and control

One week 3 months

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INCIDENCE OF POCD(according age group n=1082)

Age (yr) 1 Week 3 months18 – 39 36.6% 5.7%40 - 59 30.4% 5.6%

> 60 41.4% 12.7%

Monk et al: Anesthesiology 2008; 108:18-30.

Risk factors for POCD

Risk factorsPatient Advence age,

pre-existing cerebral, cardiac or vascular disease,preoperative mild mild cognitive impairment (MCI), low educational level, history of alcohol abuse

Surgery Extensive surgical procedure, intra-or postoperative complication, secondary surgery

Anesthesia Long-acting anesthetic, marked disturbance of homeostasis, organ ischemia due to hypoxia and hypoperfusion, intra-or postoperative anesthesiological complication.

Dtsch Arztedl Int 2014; 111(8): 119-125

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Predictors of POCD: 3 Months After Surgery

NS0.046 History of MI

NS0.021 Baseline Co-morbidityNS0.009 ASA Physical StatusNS0.003 History of Stroke

2.51 (p=0.057)0.001 Age0.86 (p=0.028) < 0.001 Years of Education

NS0.028 NYHA Status

NSNS Anesthesia TimeNSNS Baseline MMSENSNS GenderNSNS Surgery Type

Multivariate Odds Ratio Univariate P value Risk Factors for POCD

Multivariate c-statistic = 0.671 (p = 0.003)

Monk et al. Anesthesiology 2001; 95: A-50

Preoperative factors• Age• Pre-existing diseases• Low level if education• Cognitive function

Hospital associated factors• Change in environment• Length of hospital stay• Sleep deprivation (noise and monitoring)

Postoperative factors• Inflammatory response• Postoperative pain• Stress-induced sleep disturbances• Opioids

Interventions• Minimal invasive surgery• Pain control - non-opioid• Early discharge• Pharmacological sleep improvement• Reduction in nighttime noise

POCD

Pathogenic mechanism for POCD and possible intervention

Act Anaesthesiol Scand 2010, 54:951-95605/02/23 9

Continuum from Normal Aging through Mild Cognitive Impairment to Dementia

Mild cognitive impairment

Dementia

Age

Func

tion

Normal Aging

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Threshold Theory for Cognitive Decline

LesionLesion

LesionLesionProtectiveFactor

Case A Case B

Bra

in R

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apac

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A: : Protective factor (greater brain reserve capacity), lower test sensitivity, no impairmentB: Vulnerability factor (less brain reserve capacity), higher test sensitivity, impairment

Satz, Neuropsychology 1993:(7);273.

Functional impairment cutoff

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Mayo Clin Proc. 2011;86(6):885-893

Pathogenesis of cognitive decline

Proposed Mechanisms for Neuroinflammation and POCD

J Anesth Perioper Med2014; 1: 97-103.05/02/23 14

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Eckenhoff R, Prog Neuro-Psychopharm & Bio Psych, 2012

Anesthetic Risk Factors for POCD

• Cholinergic neurons in the basal forebrain regulate normal memory

• Choline reserves with aging• Anesthetic agents affect release of CNS

neurotransmitter– acetylcholine, dopamine, norepinephrine

• Difficult to postulate effects of anesthesia on memory, since mechanisms of general anesthesia are poorly understood.

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05/02/23 17Rossi et al .Anesth Analg 2014;119:947–55)

• Not been able to clearly link general anesthesia & POCD• Suggesting neurotoxicity from animal studies, but not fully explain POCD in humans• Drugs effect may play a role in postoperative cognitive decline & analgesics

Anesthesia

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Conclusion Anesthesiologists should concern about the risk of POCD by making prevention and attentive to the potential risk factors.It should be remembered that research in animal models which represent the specific characteristics of POCD in human remains unclear.With many factors still unknown, there is still a chance for sinchronized preclinical and clinical research on POCD.

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