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POSTOPERATIVE COGNITIVE
DYSFUNCTION
What should we know?
Siti Chasnak Saleh
Airlangga Univ./Soetomo Hospt.
Surabaya
03/08/...
Characterization of POCD
Memory impairment as identified by a reduced ability
to learn or recall information.
Disturbance ...
03/08/16 3
POCD
• Not detected until days or weeks after
anesthesia.
• Duration of several weeks to permanent
• Diagnosis ...
4
Long-term postoperative cognitive dysfunction
in the elderly: ISPOCD1 study
JT Moller P Cluitmans LS Rasmussen P Houx H ...
5
0
5
10
15
20
25
30
Percentage(%)
Early Late
Controls
Patients
Lancet 1998: 351-357
*
*
* p < 0.004
Incidence of POCD in ...
03/08/16 6
INCIDENCE OF POCD
(according age group n=1082)
Age (yr) 1 Week 3 months
18 – 39 36.6% 5.7%
40 - 59 30.4% 5.6%
>...
Risk factors for POCD
Risk factors
Patient Advence age,
pre-existing cerebral, cardiac or vascular disease,
preoperative m...
Predictors of POCD:
3 Months After Surgery
NS0.046History of MI
NS0.021Baseline Co-morbidity
NS0.009ASA Physical Status
NS...
Preoperative factors
• Age
• Pre-existing diseases
• Low level if education
• Cognitive function
Hospital associated facto...
Continuum from Normal Aging through
Mild Cognitive Impairment to Dementia
Mild cognitive impairment
Dementia
Age
Function
...
Threshold Theory for Cognitive Decline
LesionLesion
LesionLesionProtective
Factor
Case A Case B
BrainReserveCapacity
A:: P...
03/08/16 12
03/08/16 13
Mayo Clin Proc. 2011;86(6):885-893
Pathogenesis of cognitive decline
Proposed Mechanisms for Neuroinflammation
and POCD
J Anesth Perioper Med
2014; 1: 97-103.03/08/16 14
03/08/16 15
Eckenhoff R, Prog Neuro-Psychopharm & Bio Psych, 2012
Anesthetic Risk Factors for POCD
• Cholinergic neurons in the basal forebrain regulate
normal memory
• Choline reserves ↓ ...
03/08/16 17
Rossi 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 ex...
03/08/16 19
Conclusion
Anesthesiologists should
concern about the risk of POCD
by making prevention and
attentive to the p...
03/08/16 20
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2. prof. siti chasnak pocd 2016-updateprofsiti

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.

  • Be the first to comment

2. prof. siti chasnak pocd 2016-updateprofsiti

  1. 1. POSTOPERATIVE COGNITIVE DYSFUNCTION What should we know? Siti Chasnak Saleh Airlangga Univ./Soetomo Hospt. Surabaya 03/08/16 1
  2. 2. Characterization of POCD Memory impairment as identified by a reduced ability to learn or recall information. Disturbance in executive functioning Disturbance in attention or speed of information processing Impairment of perceptual-motor abilities Impairment in language GERIATRIC & AGING 2003;vol 6 no 10 03/08/16 2
  3. 3. 03/08/16 3 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
  4. 4. 4 Long-term postoperative cognitive dysfunction in 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 Canet P 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 Silverstein JEW 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 03/08/16
  5. 5. 5 0 5 10 15 20 25 30 Percentage(%) Early Late Controls Patients Lancet 1998: 351-357 * * * p < 0.004 Incidence of POCD in patients and control One week 3 months 03/08/16
  6. 6. 03/08/16 6 INCIDENCE OF POCD (according age group n=1082) Age (yr) 1 Week 3 months 18 – 39 36.6% 5.7% 40 - 59 30.4% 5.6% > 60 41.4% 12.7% Monk et al: Anesthesiology 2008; 108:18-30.
  7. 7. Risk factors for POCD Risk factors Patient 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 03/08/16 7
  8. 8. Predictors of POCD: 3 Months After Surgery NS0.046History of MI NS0.021Baseline Co-morbidity NS0.009ASA Physical Status NS0.003History of Stroke 2.51 (p=0.057)0.001Age 0.86 (p=0.028)< 0.001Years of Education NS0.028NYHA Status NSNSAnesthesia Time NSNSBaseline MMSE NSNSGender NSNSSurgery Type Multivariate Odds RatioUnivariate P valueRisk Factors for POCD Multivariate c-statistic = 0.671 (p = 0.003) Monk et al. Anesthesiology 2001; 95: A-50
  9. 9. 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, 54:951-95603/08/16 9
  10. 10. Continuum from Normal Aging through Mild Cognitive Impairment to Dementia Mild cognitive impairment Dementia Age Function Normal Aging 03/08/16 10
  11. 11. Threshold Theory for Cognitive Decline LesionLesion LesionLesionProtective Factor Case A Case B BrainReserveCapacity A:: Protective factor (greater brain reserve capacity), lower test sensitivity, no impairment B: Vulnerability factor (less brain reserve capacity), higher test sensitivity, impairment Satz, Neuropsychology 1993:(7);273. Functional impairment cutoff 03/08/16 11
  12. 12. 03/08/16 12
  13. 13. 03/08/16 13 Mayo Clin Proc. 2011;86(6):885-893 Pathogenesis of cognitive decline
  14. 14. Proposed Mechanisms for Neuroinflammation and POCD J Anesth Perioper Med 2014; 1: 97-103.03/08/16 14
  15. 15. 03/08/16 15 Eckenhoff R, Prog Neuro-Psychopharm & Bio Psych, 2012
  16. 16. 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. 03/08/16 16
  17. 17. 03/08/16 17 Rossi et al .Anesth Analg 2014;119:947–55)
  18. 18. • 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 03/08/16 18
  19. 19. 03/08/16 19 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.
  20. 20. 03/08/16 20

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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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