Postoperative Cognitive Dysfunction (POCD) in the elderly

By AjayModerator: Dr YOGA

POCD in the ElderlyChanges in personality

Changes in social integration

Changes in cognitive powers and skills

IncidenceSeymour ’86 Williams’92 Linn ’53 Francis’90

General Surgery Ortho Cataract Medical Hospitalization

10-15%

(All patients 5-10%)

28-60% 1-3% 25-50%

History1955,Bedford 1961,Simpson 1967,Blundell 1970,Finnish study

recommended to confine operations to necessary cases

concluded that anaesthesia had no effect and recorded benefits of surgery.

believed anaesthetic drugs, fever etc caused POCD

showed deterioration in 8% of elderly patients

Why does POCD occur?Physiologic effects of the anaesthetics: hyperventilation, hypotension or hypoxia

Role of catecholamines or cholinergic transmission

Genetic markers from dementia studies

Is POCD caused by GA or Regional?Study n Operation Age (yrs) POCD Difference

Hole’80 60 THR 56-84 Yes Yes

Kaarh’82 60 CAT >65 Yes Yes

Riis ‘83 30 THR >60 Yes No

Bigler’85 40 Hip >60 No No

Chung’87 44 TURP 60-93 Yes Yes

Hughes’88 30 THR 50-80 Yes Yes

Ghonei’88 105 Joint 25-86 Slight No

Asbjer’89 40 TURP 60-80 Yes No

Jones’90 146 THR/TKR >60 No No

Nielson’90 60 TKR 60-86 No No

Camp ‘93 169 CAT 65-98 No No

Willia’96 262 TKR >40 Yes No

Does GA per se cause POCD?

• Subtle changes in all ages• Larger deficits with surgery of shorter

duration

Study n Operation Age(Yrs) Effects

Smith ‘86 85 Ortho/Gynae./General 50-69 Yes

Chung ‘90 40 Cholecystectomy 25-83 Yes

Smith ‘91 112 TURP 48-88 Yes

Tzabar 54 General 19-70 Yes

POCD in cardiac surgeryStudy n Surgery Age(yrs) Short-term Long-term

Savageau’82 245 CABG/Valve 25-69 28% 24%

Shaw’87 312 CABG 31-70 Yes NA

Townes’89 90 CABG 40-59 Yes 11-31%

McKhann’97 172 CABG 41-86 9-30% 11-33%

POCD in cardiac surgeryLimited auto-regulatory capacity

Hypothermia

Intraoperative hypotension

Loss of pulsatile flow

Macro or micro-embolization

Particulate cellular aggregates

Common drugs causing POCDMinorTranquilizers

Anti -hypertensives

Diuretics Beta blockers Major Tranquilizer

Analgesics Others

Diazepam Methyldopa Hydrochlor-thiazide

Propranolol Haloperidol Acetyl salicylic acid

Cimetidine

Flurazepam Reserpine Thorazine Meperidine Insulin

Meprobamate Thioridazine Amoxapine

Oxazepam Amantidine

Chlorazepate

Summing up the aetiologic factorsPreoperative Intraoperative Postoperative

Physiologic and Pathologic Type of surgery Hypoxia

Drugs Duration of surgery Hypocarbia

Endocrine and metabolic Anaesthetic drugs Pain

Mental status Type of anaesthesia Sepsis

Sex Complications during surgery

Electrolyte or metabolic

Diagnosis

Diagnosis

PreventionPreoperative Intraoperative Postoperative

Detailed history of drugs Adequate oxygenation and perfusion

Treat pain

Evaluation of medical problems

Correct the electrolyte imbalance

Reassure patient and family

Detections of sensory or perceptual deficits

Adjust drug doses Keep patient informed and oriented

Mental preparation prior to surgery

Minimize the variety of drugs

Quite surrounding

Neuropsychologic testing Avoid atropine, flurazepam,scopolamine

Well-lit cheerful room

ManagementManage with extra vigilance

Delirium may signal onset of pneumonia, sepsis, MI

Reduce or stop risk associated drugs

Haloperidol- the drug of choice ; Droperidol; Chlorpromazine

Diazepam-useful in delirium tremens

Thiamine-Korsakoff’s psychosis

Avoid muscle relaxants or physical restraints; may need ABD control

Psychiatric or psychological referral

Physiotherapy and occupational therapy

ReferencesC. Dodds and J.Allision. Postoperative deficit in the elderly surgical patient.BJA 1998

Smita S. Parikh and Frances Chung.Postoperative Delirium in the Elderly.Anesth Anal 1995

Khwaja et al.Preoperative Factors Associated with Postoperative Changes in Confusion Assessment.Anesth Anal 2002

Thank you very much!