Anesthesia and geriatrics 2021 no recording
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This document discusses anesthesia and surgery risks in older patients. It defines postoperative cognitive dysfunction (POCD) and reviews risk factors. Neuroinflammation from surgery and anesthesia may cause POCD through breakdown of the blood-brain barrier and neurotoxic effects. Risk factors for POCD include age, preexisting cognitive impairment, diabetes, hypertension and sleep disorders. A comprehensive geriatric assessment evaluates medical, functional and social risks. Prevention prioritizes optimization of risk factors through treatment of medical conditions and good perioperative care. Most POCD cases resolve within months without direct treatment.
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Anesthesia and geriatrics 2021 no recording
- 1. Anesthesia and The Older Patient MARC EVANS M. ABAT, MD, FPCP, FPCGM Internal Medicine-Geriatric Medicine-Home Care Head, Center for Healthy Aging and Section of Geriatric Medicine Department of Medicine, The Medical City Clinical Associate Professor, Division of Adult Medicine, Department of Medicine, PGH
- 2. Disclosures • Lectures • Educational • Speakership • Clinical trials Support from industry
- 3. Objectives Risk assessment for the geriatric patient for surgery. Define postoperative cognitive dysfunction (POCD) and pathophysiology. Review the patient risk factors that contribute to developing POCD Discuss strategies for prevention and treatment of POCD.
- 5. Risk assessment of the geriatric patient for surgery
- 7. Fragala M.S. (2015)The Physiology of Aging and Exercise. In: Sullivan G., Pomidor A. (eds) Exercise for Aging Adults. Springer, Cham. https://doi.org/10.1007/978-3-319-16095-5_1
- 8. • Education Committee Writing Group (ECWG) of the American Geriatrics Society recommends that undergraduate students should be trained profoundly in the 13 most common geriatric syndromes dementia inappropriate prescribing of medications Osteoporosis depression incontinence sensory alterations including hearing and visual impairment delirium iatrogenic problems immobility and gait disturbances falls frailty and failure to thrive pressure ulcers sleep disorders
- 9. What is the Comprehensive Geriatric Assessment (CGA)? multidimensional, interdisciplinary diagnostic process develop a coordinated and integrated plan for treatment and long-term follow-up. emphasizes quality of life and functional status, prognosis, and outcome that entails a workup of more depth and breadth employment of interdisciplinary teams and the use of any number of standardized instruments both a diagnostic and therapeutic process http://journals.sagepub.com/doi/pdf/10.1177/107327480301000603 https://www.uptodate.com/contents/comprehensive-geriatric-assessment https://www.bmj.com/content/343/bmj.d6553
- 12. Why is it important to have a comprehensive geriatric assessment?
- 13. Postoperative cognitive dysfunction: nomenclature and definition
- 14. Postoperative neurocognitive disorders Postoperative delirium, an acute state of confusion and inattention Postoperative cognitive dysfunction (POCD), a prolonged state of cognitive impairment that predominantly affects higher-level cognitive skills and memory JAMA. 2021;326(9):863-864.
- 15. Postoperative Cognitive Dysfunction (POCD) Evered L, Silbert B, Knopman DS, Scott DA, DeKosky ST, Rasmussen LS, et al. Recommendations for the nomenclature of cognitive change associated with Anaesthesia and Surgery-20181. J Alzheimers Dis JAD. 2018;66:1–10.
- 17. a temporal relationship to anesthesia and surgery can be identified does not in any way imply causation could result from the anesthesia, the surgery, the patient, or a combination of these • occurred in the absence of perioperative hypoxemia or hypotension Anesthesia & Analgesia: August 2018 - Volume 127 - Issue 2 - p 496-505
- 18. 3-month incidence of POCD is similar for • cardiac surgery • joint arthroplasty • cardiac angiography, under oral or intravenous sedation in the absence of general anesthesia similar incidence is also seen • joint arthroplasty under regional anesthesia with sedation Anesthesia & Analgesia: May 2011 - Volume 112 - Issue 5 - p 1179-1185 Acta Anaesthesiologica Scandinavica. March 2003, Volume 47 (3), p 260–266
- 19. inflammatory response to anesthesia and surgery in susceptible individuals Proinflammatory cytokines are released after surgery into the systemic circulation directly affect the central nervous system neuroinflammation Anesthesia & Analgesia: August 2018 -Volume 127 - Issue 2 - p 496-505
- 20. Breakdown of the blood-brain barrier Microglial activation Oxidative stress Functional consequences • detrimental effects on the regulation of neurotransmitter signaling in the hippocampusexcitotoxic neuronal damage Suppression of Cholinergic Anti-inflammatory Pathway Oligomerization and aggregation of amyloid; tau hyperphosphorylation Psychiatry, 17 January 2019 https://doi.org/10.3389/fpsyt.2018.00752 Neurodegener Dis 2020;20:113–122
- 21. POCD: Patient risk factors
- 22. Predisposing Factors or Vulnerabilities Precipitating Factors or Insults High Vulnerability Low Vulnerability Less Noxious Insult Very Noxious Insult
- 23. Predisposing Factors or Vulnerabilities Precipitating Factors or Insults High Vulnerability Low Vulnerability Less Noxious Insult Very Noxious Insult Predisposing Factors or Vulnerabilities Precipitating Factors or Insults High Vulnerability Low Vulnerability Less Noxious Insult Very Noxious Insult
- 24. J Intensive & Crit Care 2016, 2:1
- 25. Risk factors for POCD After colorectal surgery • Diabetes history (OR = 8.391 [2.208–31.882], P = 0.012), • Fasting over 3 days after surgery (OR = 5.236 [1.998–13.721], P = 0.001) • SIRS score of > 3 After CABG • Inflammatory response • Postoperative pain • Postoperative delirium BMC Anesthesiology volume 19, Article number: 6 (2019) NJPH (วารสาร พ.ส.) [nternet]. 2020Aug.27 [cited 2021Nov.26];30(2):72
- 26. PCOD: Prevention and Treatment
- 27. JAMA. 2021;326(9):863-864. doi:10.1001/jama.2021.4773 Perioperative risk factors and targeted interventions for postoperative neurocognitive disorders • Hearing and vision aids • Exercise programs/Prehabilitation Functional status and baseline frailty score • Treatment and counseling Depression • Cardiac evaluation • Appropriate perioperative hemodynamic management Hypertension • Optimization of physical environment (eg, sleep hygiene, sleep protocol) • Treatment of obstructive sleep apnea Sleep disorders • Perioperative glycemic control; diabetes control Glycemia
- 28. •Treatment of alcohol and substance use disorders •Monitoring for substance withdrawal syndromes Alcohol and other substance use/dependence •Cessation of nonessential medications •Review of essential medications •Monitoring for polypharmacy and potential interactions Medication management •Perioperative nutritional plan; supplementation if indicated •shortened fluid fast considered, clear liquids encouraged up to 2 hrs before surgery •dentures made available; resumption of diet as early as feasible Nutritional status •Directed pain history •Ongoing education regarding safe and effective use of institutional treatment options •Multimodal, individualized pain control with vigilant dose titration Perioperative pain •Referral to a social worker and/or pastoral care, if with concerns Family and social support system JAMA. 2021;326(9):863-864. doi:10.1001/jama.2021.4773
- 29. Meta-analysis of medications for POCD Significant • Anti-inflammatory agents in general (OR 0.67, CI 0.49- 0.91, p<0.01) • COX-2 inhibitors (OR 0.31, CI 0.17-0.56, p<0.001) Not significant • Ketamine • Lidocaine • Dexamethasone • Magnesium • Melatonin • 17β-estradiol J Neurol Neurosci Vol.11 No.3: 318.
- 30. Other medications being studied Minocycline Cholinergic agents • Sugammadex • Donepezil Targeted cytokine inhibition • Anakinra • Etanercept • Tocilizumab Antioxidative • Statins • N-acetylcysteine Pro-neuronal • Dexmedetomidine • Amantadine Others • Cannabinoids, turmeric Psychiatry, 17 January 2019 | https://doi.org/10.3389/fpsyt.2018.00752
- 31. Treatment Most cases resolve in a few months Same as in preventive measures
- 32. Summary There are physiologic changes and geriatric syndromes in the older surgical patient A comprehensive geriatric assessment is important to help assess the risks and predisposing factors for postoperative cognitive dysfunction, and provide points for therapeutic interventions There is a temporal relationship between the signs and symptoms, surgery and anesthesia Neuroinflammation is a key pathophysiologic process Several patient-related risk factors are identified Preventive strategies are multimodal and interdisciplinary Most cases resolve in a few months, no direct treatment modalities; management is similar to that used in preventive strategies
Editor's Notes
- Thank you to the Philippine Society of Anesthesiologists for inviting me over to talk about our older patients undergoing surgery, and the concerns that arises during the interaction of the older patient, the procedure and the anesthesia
- These are my disclosures
- We will tackle the following objectives: We will go through the general process of risk assessment for the older patient for surgery Define postoperative cognitive dysfunction or PCOD and the general mechanisms of its pathophysiology Review patient risk factors And Discuss prevention and treatment strategies for PCOD
- Some may think that putting an older patient under anesthesia, or even sedation, for any procedure is like putting the patient in a comfy sleep. But we do recognize that the older patient has many intricacies and idiosyncrasies that need to be considered, especially with the entire course of the patient, from the pre-operative period, down to the post-operative periods, and oftentimes, even weeks to months thereafter
- We will now discuss approaching risk assessment for the geriatric patient prior to surgery. We shall not touch on the cardiopulmonary aspect of the perioperative assessment of the older surgical patient, but deal with other aspects of care that need to be addressed.
- There will be many physiologic changes brought about by aging that will impact the clinical course of the patient. On top of these, there is the concept of the geriatric syndromes, or collections of symptoms or findings that can occur uniquely to the older patient, and must also be assessed and managed prior to a surgical procedure
- These are some of the general changes that happen to the body of the older patient. All of these can interact together with any stressor and with each other, and lead to clinical concerns.
- These are the most common geriatric syndromes seen in the older patient. These phenomena are usually manifestations of the vulnerable organ systems in the older patient and more importantly, may be triggered by stressors external to these said organ systems. For example, delirium can be a manifestation of many conditions like infections, dehydration and electrolyte imbalance, or even drug effects.
- The comprehensive geriatric assessment or CGA is a multidimensional interdisciplinary process that acts both as a diagnostic and therapeutic process, yielding a coordinated and integrated plan for management of the older patient The process involves the use of standardized intruments and interdisciplinary teams, and may take a varying span of time to complete There are no specific or singular CGA pattern, but the model may vary depending on the site and level of care.
- The CGA involves domains other than the usual medical history and physical exam of the patient. Also assessed are functionality, behavior and neurological, emotional, environmental, spiritual and social support.
- These are some specific instruments that may be used for assessment of the different domains. Most of these are available freely and can be adapted easily to hospital practice. With regular use, these can be readily administered to the patient and provide a clearer definition of the patient’s risk profile prior to surgery A special mention must be made regarding comprehensive medication assessment. The 2019 Beer’s criteria provides a list of medications that: Are potentially inappropriate potentially inappropriate medications to avoid in older adults with certain conditions; medications to be used with considerable caution in older adults medication combinations that may lead to harmful interactions; and a list of medications that should be avoided or dosed differently for those with poor renal function.
- So why is it important to do the CGA? We need to know our older patient well prior to surgery and anesthesia, since there is a possibility of postoperative cognitive dysfunction, complicating the course of the patient
- So what is Postoperative cognitive dysfunction?
- The umbrella term for these conditions is Postoperative neurocognitive disorders, under which it may be postoperative delirium, which is an acute confusion and inattention, vs. postoperative cognitive dysfunction, which is a more prolonged state of cognitive impairment
- Fluctuating attention, mental status and consciousness up to 1 week following surgery is considered as POSTOPERATIVE DELIRIUM. However, if cognitive decline persists up to within 30 days from the procedure, it is considered as DELAYED NEURCOGNITIVE RECOVERY. Persistence of the cognitive decline from 1 to 12 months after procedure, which cannot be accounted for by any other condition, is considered POSTOPERATIVE COGNITIVE DYSFUNCTION Note that the DSM-5 definition for either a mild or major neurocognitive disorder should be satisfied also. There should be a cognitive concern from either the patient, informant or the clinician and an objective evidence of decline of 1-2 standard deviations. IADLS or ADLS may or may not be impaired.
- Let’s discuss a bit about the pathophysiology leading to POCD
- Among patients with POCD, there is a temporal relationship between the patient, anesthesia and the surgical procedure; but this does not in any way imply direct causation. In fact, it may be a multiplicity of factors from each of these components, leading to development of POCD in a patient. In many instances, for example, POCD developed in the absence of factors like hypotension or hypoxemia.
- It has been noted that the incidence of POCD is similar in a variety of procedures of varying complexities, including cardiac surgery, joint arthroplasty and even cardiac angiography. It can occur whether there was general or regional anesthesia or even under sedation alone.
- An underlying theme in the pathophysiology of POCD is the inflammatory response to surgery and anesthesia in susceptible or at-risk older patients. Basically, pro-inflammatory cytokines are released into the systemic circulation, reaches and affects the central nervous system, leading to a cascade of events causing NEUROINFLAMMATION
- Several findings have been noted or proposed in relation to neuroinflammation as a mechanism for POCD: Peripheral pro-inflammatory cytokines disrupt BBB permeability via COX-2 upregulation and matrix metalloproteinases (MMPs), allowing pro-inflammatory cytokines to enter the CNS Microglial activation continue to upregulate expression of pro-inflammatory cytokines, thus amplifying neuroinflammation and contributing to the development of POCD Oxidative stress also occurs, either via depletion of antioxidants as a baseline characteristic or due to the stress of surgery, or as part of the inflammatory response that is activated. Pro-inflammatory cytokines can have detrimental effects on the regulation of neurotransmitter signaling in the hippocampus, ultimately resulting in excitotoxic neuronal damage and resulting cognitive impairment. Mechanisms involve include increased NMDA signaling and downregulation of GABA receptors Peripheral pro-inflammatory cytokines are also involved in regulating the inflammatory response via a vagal reflex arc. The efferent arc of this reflex originates from fibers within the dorsal motor nucleus of the vagus, sending signals to the celiac ganglion, eventually regulating cataecholamic efferents in the splenic nerve. These later endings activate T-lymphocytes that upregulate choline acetyltransferase, leading eventually to activation of macrophages that inactivate NF-kappa-B. Anticholinergic agents given to patients may precipitate POCD, but it is not clear if the mechanism involves effects on this vagal reflex arc Finally there seems to be an increase in oligomerization and aggregation of amyloid, and increased tau phosphorylation, both of which are similarly noted in Alzheimer’s disease.
- We will know focus on patient risk factors for POCD
- Those who are vulnerable due to the multiplicity of their risk factors only needs a minor insult to manifest with problems. On the other hand, those with minimal risk factors or with minimal vulnerability would take either one big insult or successive moderate insults to manifest with problems
- Different older patients may have different inherent vulnerabilities for a given risk profile, and consequently may also react adversely in varying levels for the same precipitant insult.
- Advancing age (>60 yo), baseline cognition, lower educational level, visual and hearing impairment, alcohol and drug withdrawal, sleep deprivation, other neurodegenerative diseases like Parkinson’s and diabetes, increase risk for POCD. Some of the hospital-related factors may also be patient-centric, including postoperative infections, respiratory complications, hypoxia, dysglycemia, pain, use of vasoactive drugs and benzodiazepines (both pre- and postop).
- In these studies, similar risk factors were reported. Of not is the presence of postoperative delirium as a risk factor. The previous risk factors mentioned as predisposing for POCD are also risk factors for postoperative delirium in the immediate week after surgery.
- Finally, we shall talk about prevention and treatment of POCD
- Preventing or minimizing the risk for POCD involves multidimensional and multimodal interventions. Exercise or prehabilitation and sensory aids should be provided. Depression should be addressed prior to the surgery. Hypertension should be adequately controlled with appropriate medications, especially those with low risk for inducing cognitive changes. An optimal environment for sleeping should be provided, and those with sleep apnea should be provided appropriate interventions like CPAP. Blood sugar should be judiciously regulated, with consideration for both hyper- and hypoglycemia.
- Alcohol and other substance abuse disorders should be managed, and the possibility of withdrawal syndromes be monitored during hospitalization. Medications should be reviewed, with cessation of non-essential medications, and monitoring for any adverse reactions related to the medications, including drug interactions. There should be a perioperative nutrition plan, with shortened fluid fasts. Diet should be resumed as early as possible, with dentures allowed to be used for meals. Adequate and judicious pain control should be achieved. Concerns regarding family and social support in the post-operative period should be addressed.
- In this meta-analysis, medications were assessed for efficacy in preventing POCD. Those with significant effects include anti-inflammatory agents in general, especially COX-2 inhibitors. Those with no statistically significant effects include ketamine, lidocaine, dexamethasone, magnesium, melatonin and 17B estradiol.
- Several other interventions are being studied, based on the purported pathophysiology of POCD. There are trials ongoing for several of these agents, while some have been studied mainly in animal models.
- Once POCD is present, there is really no generally accepted treatment except for instituting the same multimodal and multidimensional interventions for prevention. Most cases actually resolve in a few weeks or months.
- In summary, we have discussed the changes that happen in the older person and the need for a comprehensive geriatric assessment to fully elucidate the risk profile of the older patient. We have defined what postoperative cognitive dysfunction is, and its temporal relationship with the surgery and anesthesia among vulnerable patients. Neuroinflammation is a key pathophysiologic process. Preventive strategies can be employed to minimize the risk for POCD. Most cases resolve, and since there is no defined direct treatments, management is similar to those used in prevention.
- Thank your for listening and take care everyone.