International Observational Study on Perioperative Cognitive Trajectories (POCD Census International/PCI)

Evaluation of POCD-Census Prospective, International Observation Study

The purpose of this international, multi-centre observational study is to describe perioperative cognitive changes (pre-existing neurocognitive disorder [NCD], postoperative delirium [POD] and Postoperative Cognitive Dysfunction [POCD]) up to five years after elective surgery in a mixed cohort. Measurements and definitions of cognitive outcomes will be based on current consensus and used for further harmonization in future clinical studies on perioperative cognitive trajectories. This is a feasibility approach to identify an effective screening procedure and estimate loss to follow up rates for the planning of future intervention studies. Data from this trial may also serve to facilitate and implement time effective cognitive screening and risk stratification concerning postoperative cognitive decline in the anaesthesiological preoperative assessment.

Study Overview

• Status: Active, not recruiting
• Conditions: Neurocognitive Disorders; Postoperative Cognitive Deficit (POCD)

Detailed Description

This international observational study on perioperative cognitive trajectories (POCD census international/PCI) has been designed as a pilot study to allow a peer reviewed process of four international test centres on measurement of perioperative acute and long-term cognitive outcome. Data from standard clinical treatment of 500 patients age ≥ 70 years scheduled for elective surgery (stratified according to preoperative assessment of frailty and monitored by intraoperative depth of anaesthesia) will be supplemented by guideline conform delirium- analgesia- and sedation screening until day 5 after surgery, I-Pad based neuropsychological testing [Cambridge Neuropsychological Test Automated Battery - CANTAB connect] pre-operatively, 3 months, 1- 2- and 5 years after surgery, a paper-based verbal fluency test (animal naming test from Addenbrooke's Cognitive Examination Revised (ACE-R)), a paper based test on executive function (Trailmaking Test), cognitive screening tests (Montreal Cognitive Assessment (MOCA) and Mini-Cog), and concomitant questionnaires to assess functional status, self- and by proxy rating of cognitive performance, psychological factors (depression, perioperative anxiety, stress, resilience and coping), social support, perioperative anxiety, stress, resilience and coping, as well as risk consumption of alcohol and tobacco.

A non-surgical control group of 100 study participants who are not scheduled for surgery will be followed up at the same time points as the surgical cohort for scaling of cognitive data and definition of cut off values to define significant cognitive decline.

Secondary outcome measures of this trial comprise levels and changes in molecular biomarkers involved in Alzheimer's dementia etiology sampled from spinal fluid on induction of spinal anaesthesia and sampled from blood in all patients.

Retrospective comparison collective (01/01/2017 to 01/01/2022):

A group of around 8000 surgical patients aged 65 and older at the Charité will be examined as control group. This control group is required for various questions, especially influencing factors with regard to the postoperative outcome of delirium, and aims to test the predictive ability of clinical routine data with regard to postoperative delirium. As part of the multimodality of this retrospective comparative cohort study, in cooperation with PD. Dr Scheel and in collaboration with Prof. Dr. Finke, cranial MRI scans analyzing routine data from the Institute of Neuroradiology. The subject of the investigation is initially the entire electronic routine data of the control group, including the existing cranial MRI scans.

• Study Type: Observational
• Enrollment (Actual): 173

Contacts and Locations

Study Locations

• Germany
  • Berlin, Germany, 10117
    • Arbeitsbereich Physikalische Medizin
  • Berlin, Germany, 12163
    • Internistische Hausarztpraxis
  • Berlin, Germany, 13353
    • Department of Anesthesiology and Intensive Care Medicine Berlin (CCM/CVK), Charité - Universitätsmedizin Berlin

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 70 years and older (Older Adult)
• Accepts Healthy Volunteers: Yes

• Sampling Method: Probability Sample

Study Population

Surgical patients aged ≥70 years

Description

Inclusion Criteria:

• Surgical patients at Campus Virchow- Klinikum and Campus Charité Mitte
• Aged ≥ 70 years
• Informed consent

Exclusion Criteria:

• Manifest dementia
• Lack of willingness to store and disseminate pseudonymized disease data as part of the clinical trial
• Lack of readiness to participate in the follow-up examinations and contact to make an appointment
• Placement in an institute under judicial or official orders (according to German drug Law §40 (1) 4)
• Persons without a permanent residence or other circumstances that call into question the availability by telephone or post for postoperative examination
• Employees of the respective study centers
• illiteracy
• Patients with a neuropsychiatric condition that limits the performance of neurocognitive testing
• Patients with hearing and / or vision problems that limit the performance of neuro-cognitive testing
• Simultaneous participation in a prospective clinical intervention study (apart from the desired parallel participation in the anaesthesiological study Praep-Go, EA1/225/19)

Study Plan

How is the study designed?

Design Details

• Observational Models: Cohort
• Time Perspectives: Prospective

Number of groups / cohorts

2

Cohorts and Interventions

Group / Cohort
Study group; Surgical patients aged ≥70 years
Control group; Healthy subjects, aged ≥70 years, American Society of Anesthesiologists (ASA) I+II+III, no surgery

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of postoperative cognitive dysfunction (POCD)	Neuropsychological testing	Up to 1 year

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Incidence of postoperative cognitive dysfunction (POCD)	Neuropsychological testing	Up to 5 years
Positive cognitive screening	Short neuropsychological testing	Up to 5 years
Mild Neurocognitive Disorder	Definition according to DSM-V as proposed in Evered L et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery. Br J Anaesth, Anesthesiology, Can J Anesth, Anesth Analg, J Alz Dis, acta scandinavica anaesthesiologica (Joint Publication) 2017; Accepted, In Press. We will use an I-pad based neuropsychological test battery (CANTAB connect), and cognitive screening instruments (MOCA, Mini-Cog™ and Animal naming test on verbal fluency from ACE-R) for assessment of cognitive function, MMQ and IQ-code for self- or by proxy reported cognitive concern and ADL/IADL for assessment of functional status. Mild/major Neurocognitive Disorder measured at baseline (pre-existing NCD) 3 months and 1 year (with specifier 'POCD'), 2- and 5 years after surgery	Up to five years
Major Neurocognitive Disorder	Definition according to DSM-V as proposed in Evered L et al. Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery. Br J Anaesth, Anesthesiology, Can J Anesth, Anesth Analg, J Alz Dis, acta scandinavica anaesthesiologica (Joint Publication) 2017; Accepted, In Press. We will use an I-pad based neuropsychological test battery (CANTAB connect), and cognitive screening instruments (MOCA, Mini-Cog™ and Animal naming test on verbal fluency from ACE-R) for assessment of cognitive function, MMQ and IQ-code for self- or by proxy reported cognitive concern and ADL/IADL for assessment of functional status. Mild/major Neurocognitive Disorder measured at baseline (pre-existing NCD) 3 months and 1 year (with specifier 'POCD'), 2- and 5 years after surgery	Up to five years
Cerobrospinal fluid biomarker for diagnosing dementia	Patients for spinal anesthesia who consented on lumbar puncture receive biomarkers analysis from spinal fluid (beta Amyloid 1-40, beta-Amyloid 1-42, beta-Amyloid Ratio (42/40*10), phospho-TAU, Protein 14-3-3, PRPSc, TAU (Gesamt-Tau)).	Up to five years
Blood biomarker for diagnosing dementia	Patients consented on blood sampling receive biomarker analysis from blood (Apolipoprotein E).	Up to five years
Findings of memory consultation session		Up to five years
Comorbidities	Comorbidities will be quantified by use of Charlson Comorbidity index	Up to five years
Malnutrition 3	Malnutrition is measured by weight	Up to five years
Dental health	The dental status is determined by tooth doctors	Up to five years
Sarcopenia	The composite outcome measure "Sarcopenia" is defined by the following three criteria: 1) low muscle strength (hand grip strength), 2) low muscle quantity (calf circumference and 3) low physical performance (gait speed). Criterion (1) identifies probable sarcopenia, additional documentation of criterion (2) confirms sarcopenia diagnosis, and if all criteria (1), (2) and (3) are met, sarcopenia is considered severe.	Up to five years
Calf circumference	Calf circumference is measured in a standardized position and documented in centimeter.	Up to five years
Arm circumference	Arm circumference is measured in a standardized position and documented in centimeter.	Up to five years
Adherence to Mediterranean diet (MD)	Adherence to Mediterranean diet (MD) is measured with a German Mediscore, could range from 0 to 9, with higher scores (6-9) indicating greater MD adherence.	Up to five years
Nutrition in the hospital	Participants will be followed for the duration of hospital stay, an expected average of 7 days	Up to five years
Physical activity	Physical activity is evaluated by interviewing the Patient.	At the beginning of the observation
Surgical risk	Surgical risk will be described by type and length of surgery and perioperative cardiac risk estimation as described in Anästh Intensivmed 2017; 58:349-364.	Participants will be followed up during surgery, an estimated duration of 1 hour
Anaesthesiological Risk 1	Anaesthesiological risk will be described by American Society of Anesthesiologists Classification (ASA Class)	At the beginning of the observation
Anaesthesiological Risk 2	Anaesthesiological risk will be measured by length of anesthesia	Participants will be followed up during surgery, an estimated duration of 1 hour
Anaesthesiological Risk 3	Anaesthesiological risk will be measured by type of anaesthesia	Participants will be followed up during surgery, an estimated duration of 1 hour
Intraoperative depth of anaesthesia	Intraoperative depth of sedation will be monitored with changes in the pattern and power spectrum of EEG-raw data measured with the Masimo SedLine® brain function monitoring for Root®, Narcotrend®, BIS™ and additionally quantified by indices [e.g. PSI or BIS-index] and burst suppression ratio.	Participants will be followed up during surgery, an estimated duration of 1 hour
Depth of sedation on the Intensive Care Unit	Sedation is measured by Richmond Agitation Sedation Scale.	Participants will be followed for the duration of intensive care unit stay, an expected average of 5 days
Sedation on the peripheral ward	Sedation is measured by Richmond Agitation Sedation Scale.	Participants will be followed for the duration of hospital stay, an expected average of 7 days
Agitation on the peripheral ward	Agitation describes a clinical state in which the patient may be impulsive and attempt to get out of bed, to wander, and to fall (which may lead to further injury or death) and attempt to remove IV lines, tubes, or catheters.	Participants will be followed for the duration of hospital stay, an expected average of 7 days
Incidence of postoperative delirium	Postoperative delirium rate, defined according to Diagnostic and Statistical Manual of Mental Disorders (DSM-V), CAM/CAM-ICU, Nu-DESC and Chart Review.	Up to 5 days
Severity of postoperative delirium	Postoperative delirium rate, defined according to Confusion assessment method - severity(CAM-S); Delirium Rating Scale Revised (DSR-R-98), Intensive Care Delirium Screening Checklist (ICDSC) and Nursing Delirium Screening Scale (Nu-DESC).	Up to 5 days
Pain scale for patients able of pain self-assessment	Pain during hospital stay will be measured with the Numeric Rating Scale (NRS-V).	Up to hospital discharge, an expected average of 5 days
Pain scales for patients unable of pain self-assessment	For patients unable of pain self-assessment (e.g. ventilated patients, patients in delirious state or patients with stroke affecting language skills) observer-rated pain scales will be applied: Behavioural Pain Scale (BPS for ventilated) and BPS-NI (for non-ventilated) patients, Critical-Care Pain Observation Tool (CPOT) during hospital stay.	Up to hospital discharge, an expected average of 5 days
Intensive care unit length of stay	Intensive care unit length of stay describes every day spent in an ICU bed.	Participants will be followed for the duration of intensive care unit stay, an expected average of 5 days
Hospital length of stay	Hospital length of stay describes every day spent in an hospital.	Participants will be followed for the duration of hospital stay, an expected average of 7 days
Perioperative Anxiety	Perioperative anxiety will be measured with APAIS preoperatively and the Faces Anxiety Scale (FAS) and during hospital stay.	Up to 5 days
Perception of stress	Stress is measured by Perceived Stress Questionnaire 20	Up to 5 days
Stress level	Stress level is measured by stress thermometer	Up to 5 days
Generalized anxiety	Anxiety will be measured with the Generalized Anxiety Disorder 7-Item Scale (GAD-7)	Up to 5 days
Depression	Depression is measured by PHQ-8. Scores represent:0-5 = mild, 6-10 = moderate, 11-15 = moderately severe, 16-20 = severe depression	Up to 5 years
Quality of sleep	Quality of sleep is measured by the Insomnia Severity Index.	Up to 5 years
Routine laboratory		Up to hospital discharge, an expected average of 7 days
Organ dysfunctions	Organ dysfunctions are evaluated according to the Clavien-Dindo classification of surgical complications	Up to hospital discharge, an expected average of 7 days
Subjective/By proxy assessment of cognitive impairment		Up to five years
Medication	Prescribed regular drug intake from baseline at all follow ups including perioperative application of drugs, infusions and transfusions will be evaluated.	Up to 5 years
Quality of life	Quality of life will be measured with the EQ-5D-5L	Up to 5 years
Level of dependency	Level of dependency will be measured with with ADL/IADL, single items concerning patients' living situation and the BSSS-17 (Berlin Social Support Scales).	Up to 5 years
Plausibility check variables	Variables affecting performance of cognitive testings	Up to 5 years
Re-admission	Hospital readmission is an episode when a patient who had been discharged from a hospital is admitted again within a specified time interval.	Up to 5 years
Revison surgery	Surgery performed to replace or compensate for a failed implant or to correct undesirable sequelae of previous surgery.	Up to 5 years
Outpatient treatment	Treatment outside of the hospital in an associated facility for diagnosis or treatment.	Up to 5 years
Mortality	The number of deaths in a given period.	Up to 5 years
Dementia	Dementia reported as clinical diagnosis based on DSM-5 criteria for major NCD either through neuropsychological evaluation at a memory clinic or as a research diagnosis based on neuropsychological test values (CANTAB/MOCA), cognitive concern (MMQ/IQCODE) and functionality (ADL/IADL).	Up to 5 years
Motivational incongruence	The incongruence questionnaire (Der Inkongruenzfragebogen)	Up to five years
Leisure behavior	Questionnaire on frequency of cognitively stimulating leisure activities	Up to five years
Demographic variables		Up to five years
Living conditions		Up to five years
Postoperative electroencephalography (EEG) spectral analysis with band power	Spectral analysis with band power are measured by EEG at third postoperative day and delirium dependent until postoperative day 7.	Up to seven days
Evaluation of pain	Pain is measured with dolosys paintracker	Up to three months
Loneliness	Loneliness is measured with the UCLA-Loneliness-Scale (3 items)	Up to five years
Social support	Social support is measured with the Berliner Social-Support Skalen BSSS-17	Up to five years
Living situation	Living situation is measured with te question: How do you live?	Up to five years
Nutritional status	Changes in the nutritional status after elective surgery are measured by a questionnaire.	Up to five years
Malnutrition 1	Malnutrition is measured by the Body mass index	Up to five years
Malnutrition 2	Malnutrition is measured by weight	Up to five years
Duration of Delirium	Duration of postoperative delirium, defined according to medical evaluation, measured in days	Participants will be followed for the duration of hospital stay, an expected average of 7 days

Other Outcome Measures

Outcome Measure	Measure Description	Time Frame
Obesity 1	Obesity is measured by body mass index (BMI)	At the beginning of the observation
Obesity 2	Obesity is measured by waist to hip ratio	At the beginning of the observation
Variables of adjusting	Reading / writing weakness, hendedness, native speaker	At the beginning of the observation
Frailty	Frailty will be measured by Fried's criteria (Physical Frailty Phenotype), Fried et al: Frailty in older adults: evidence for a phenotype. J.Gerontol.A Biol.Sci.Med.Sci. 2001; 56: M146-M156 and evaluated in a short comprehensive geriatric assessment as decribed by Birkelbach, O. et al. Warum und wie sollte ich Frailty erfassen? - ein Ansatz für die Anästhesieambulanz. Anasthesiol. Intensivmed. Notfallmedizin Schmerztherapie 52, 765-776 (2017).	At the beginning of the observation
Cognitive Reserve	Level of education (years of formal training, last occupation, ISCED-2011 and crystalline intelligence [IQ-variable calculated with NART/MWT-A or other national equivalent ] will be used to evaluate cognitive reserve.	At the beginning of the observation
Crystalline Intelligence	Mehrfachwahl-Wortschatz-Intelligenztest (MWT-A) and National Adult Reading Test (NART)	At the beginning of the observation
Previous professional activity	Interview guide employment situation and previous professional activity adapted to Engstler (2017); Classification according to ISCO 08; Workload indices according to Kroll (2011)	At the beginning of the observation
Delusion proneness	Delusion proneness is measured by Peter's Delusion Inventory	At the beginning of the observation
Physical activity	History of physical activity less than 30 minutes / day (i.e. moderate increase in heart rate due to fast walking, cycling or other exercise)	At the beginning of the observation
Pre-operative electroencephalography (EEG) spectral analysis with band power	Spectral analysis with band power are measured by EEG	At the beginning of the observation
Preoperative Cognitive Impairment (PreCI)	Preoperative Cognitive Impairment (PreCI) is measured by computerized and paper pencil tests	At the beginning of the observation

Collaborators and Investigators

• Sponsor: Charite University, Berlin, Germany

Study record dates

Study Major Dates

• Study Start (Actual): June 8, 2018
• Primary Completion (Estimated): December 1, 2024
• Study Completion (Estimated): December 1, 2024

Study Registration Dates

• First Submitted: May 17, 2018
• First Submitted That Met QC Criteria: May 17, 2018
• First Posted (Actual): May 30, 2018

Study Record Updates

• Last Update Posted (Actual): March 13, 2024
• Last Update Submitted That Met QC Criteria: March 12, 2024
• Last Verified: March 1, 2024

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Mental Disorders; Cognitive Dysfunction; Cognition Disorders; Neurocognitive Disorders
• Other Study ID Numbers: PCI

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No