Postoperative cognitive dysfunction - current preventive strategies

Nalini Kotekar, Anshul Shenkar, Ravishankar Nagaraj, Nalini Kotekar, Anshul Shenkar, Ravishankar Nagaraj

Abstract

Improving trends in global health care have resulted in a steady increase in the geriatric population. However, as the population ages, surgery is being performed more frequently in progressively older patients and those with higher prevalence of comorbidities. A significant percentage of elderly patients experience transient postoperative delirium following surgery or long-term postoperative cognitive dysfunction (POCD). Increasing age, educational level, pre-existing mental health, and comorbidities are contributory factors. Comprehensive geriatric assessment provides an objective evaluation on overall medical, social, mental, and functional well-being with scope for preoperative optimization. Preventive strategies for POCD target the surgical and patient-related factors as well as the utilization of the concept of stress-free anesthesia and surgery, that is, Enhanced Recovery After Surgery. This includes care bundles and protocols for the perioperative period which improves outcomes in the elderly. Research on biomarkers of neural injury in POCD is gaining momentum. Pharmacologic agents such as acetylcholine esterase inhibitors promise to have a vital role in the management of POCD but exhibit undesired side effects. Interventions to reduce oxidative stress and neuroinflammation could prove beneficial. Preventive strategies, early recognition, and management of perioperative risk factors seems to be, by far, the best modality to deal with POCD till further progress in therapeutic interventions evolve.

Keywords: cognitive dysfunction; enhanced recovery; geriatric anesthesia; neuroinflammation; neuronal injury; prehabilitation.

Conflict of interest statement

Disclosure The authors report no conflicts of interest in this work.

References

    1. Dodds C, Kumar CM, Servin F. Cognitive Dysfunction and Sleep Disorders Anaesthesia for Elderly Patients. Oxford Anaesthesia Library; Oxford, UK: Oxford University Press; 2017. Chapter 13: Non-theatre anaesthesia and the elderly; pp. 113–123.
    1. Dodds C, Allison J. Postoperative cognitive deficit in the elderly surgical patient. Br J Anaesth. 1998;81(3):449–462.
    1. Kotekar N, Kuruvilla CS, Murthy V. Post-operative cognitive dysfunction in the elderly: a prospective clinical study. Indian J Anaesth. 2014;58(3):263.
    1. Newman MF, Kirchner JL, Phillips-Bute B, et al. Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery. N Engl J Med. 2001;344(6):395–402.
    1. van Harten AE, Scheeren TW, Absalom AR. A review of postoperative cognitive dysfunction and neuroinflammation associated with cardiac surgery and anaesthesia. Anaesthesia. 2012;67(3):280–293.
    1. Wu CL, Hsu W, Richman JM, Raja SN. Postoperative cognitive function as an outcome of regional anesthesia and analgesia. Reg Anesth Pain Med. 2004;29(3):257–268.
    1. Brown EN, Pardon PL. The aging brain and anaesthesia. Curr Opin Anaesthesiol. 2013;26:414–419.
    1. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study. Lancet. 1998;351(9106):857–861.
    1. Culley DJ, Monk TG, Cosby G. Post-operative Central Nervous System Dysfunction, Geriatric Anaesthesiology. 2nd ed. Vol. 9. Springer; UK: pp. 123–136. Chapter.
    1. Sundström A, Marklund P, Nilsson LG, et al. APOE influences on neuropsychological function after mild head injury: within-person comparisons. Neurology. 2004;62(11):1963–1966.
    1. Abildstrom H, Christiansen M, Siersma VD, Rasmussen LS, ISPOCD2 Investigators Apolipoprotein E genotype and cognitive dysfunction after noncardiac surgery. Anesthesiology. 2004;101(4):855–861.
    1. Hindman BJ. Emboli, inflammation, and CNS impairment: an overview. Heart Surg Forum. 2002;5(3):249–253.
    1. Sulek CA, Davies LK, Enneking KF, Gearen PA, Lobato EB. Cerebral microembolism diagnosed by transcranial doppler during total knee arthroplasty. Anesthesiology. 1999;91(3):672.
    1. Ogino Y, Tatsuoka Y, Matsuoka R, et al. Cerebral infarction after deflation of a pneumatic tourniquet during total knee replacement. Anesthesiology. 1999;90(1):297–298.
    1. Kehlet H. The surgical stress response: should it be prevented? Can J Surg. 1991;34(6):565–567.
    1. Lv L, Shao YF, Zhou YB. The enhanced recovery after surgery (ERAS) pathway for patients undergoing colorectal surgery: an update of meta-analysis of randomized controlled trials. Int J Colorectal Dis. 2012;27(12):1549–1554.
    1. Spanjersberg WR, Reurings J, Keus F, van Laarhoven CJ. Fast track surgery versus conventional recovery strategies for colorectal surgery. Cochrane Database Syst Rev. 2011;2(2):CD007635.
    1. Sethi AK, Kochhar A, Ahmad Z. Enhanced Recovery After Surgery. In: Sehgal R, Trikha A, editors. Yearbook of Anesthesiology-6. New Delhi, India: Jaypee Brothers Medical Publishers (P) Ltd; 2017. pp. 152–163.
    1. Khan S, Gatt M, Horgan A, et al. ASGBI: Issues in professional practise guidelines for implementation of enhanced recovery protocols. ASGBI, London: 2009. [Accessed October 31, 2018]. Available from: .
    1. Heyn P, Abreu BC, Ottenbacher KJ. The effects of exercise training on elderly persons with cognitive impairment and dementia: a meta-analysis. Arch Phys Med Rehabil. 2004;85(10):1694–1704.
    1. Moran J, Guinan E, Mccormick P, et al. The ability of prehabilitation to influence postoperative outcome after intra-abdominal operation: A systematic review and meta-analysis. Surgery. 2016;160(5):1189–1201.
    1. Mandal PK, Simplaceanu V, Fodale V. Intravenous anesthetic diazepam does not induce amyloid-beta peptide oligomerization but diazepam co-administered with halothane oligomerizes amyloid-beta peptide: an NMR study. J Alzheimers Dis. 2010;20(1):127–134.
    1. Mandal PK, Bhavesh NS, Chauhan VS, Fodale V. NMR investigations of amyloid-β peptide interactions with propofol at clinically relevant concentrations with and without aqueous halothane solution. J Alzheimers Dis. 2010;21(4):1303–1309.
    1. Futier E, Constantin J-M, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. Survey of Anesthesiology. 2014;58(4):169–171.
    1. Wuethrich PY, Burkhard FC, Thalmann GN, Stueber F, Studer UE. Restrictive deferred hydration combined with preemptive norepinephrine infusion during radical cystectomy reduces postoperative complications and hospitalization time: a randomized clinical trial. Anesthesiology. 2014;120(2):365–377.
    1. Hui DS, Morley JE, Mikolajczak PC, Lee R. Atrial fibrillation: A major risk factor for cognitive decline. Am Heart J. 2015;169(4):448–456.
    1. Gaita F, Caponi D, Pianelli M, et al. Radiofrequency catheter ablation of atrial fibrillation: a cause of silent thromboembolism? Magnetic resonance imaging assessment of cerebral thromboembolism in patients undergoing ablation of atrial fibrillation. Circulation. 2010;122(17):1667–1673.
    1. Schrickel JW, Lickfett L, Lewalter T, et al. Incidence and predictors of silent cerebral embolism during pulmonary vein catheter ablation for atrial fibrillation. Europace. 2010;12(1):52–57.
    1. Medi C, Evered L, Silbert B, et al. Subtle post-procedural cognitive dysfunction after atrial fibrillation ablation. J Am Coll Cardiol. 2013;62(6):531–539.
    1. Pepeu G, Giovannini MG. Cholinesterase inhibitors and memory. Chem Biol Interact. 2010;187(1–3):403–408.
    1. Birks J. Cholinesterase inhibitors for Alzheimer’s disease. Cochrane Database Syst Rev. 2006;1:CD005593.
    1. Peskind ER, Potkin SG, Pomara N, et al. Memantine treatment in mild to moderate Alzheimer disease: a 24-week randomized, controlled trial. Am J Geriatr Psychiatry. 2006;14(8):704–715.
    1. Mcshane R, Areosa Sastre A, Minakaran N, Cochrane dementia and cognitive improvement group Memantine for dementia. Cochrane Database of Systematic Reviews. 2006;6(4):CD003154.
    1. Zhu CW, Livote EE, Scarmeas N, et al. Long-term associations between cholinesterase inhibitors and memantine use and health outcomes among patients with Alzheimer’s disease. Alzheimers Dement. 2013;9(6):733–740.
    1. Ha GT, Wong RK, Zhang Y. Huperzine a as potential treatment of Alzheimer’s disease: an assessment on chemistry, pharmacology, and clinical studies. Chem Biodivers. 2011;8(7):1189–1204.
    1. Schrag M, Mueller C, Zabel M, et al. Oxidative stress in blood in Alzheimer’s disease and mild cognitive impairment: a meta-analysis. Neurobiol Dis. 2013;59:100–110.
    1. Streit WJ, Mrak RE, Griffin WS, Microglia GW. Microglia and neuroinflammation: a pathological perspective. J Neuroinflammation. 2004;1(1):14.
    1. Lu B, Bdnf LB. BDNF and activity-dependent synaptic modulation. Learn Mem. 2003;10(2):86–98.
    1. Kapila AK, Watts HR, Wang T, Ma D, Wong TMD. The impact of surgery and anesthesia on post-operative cognitive decline and Alzheimer’s disease development: biomarkers and preventive strategies. J Alzheimers Dis. 2014;41(1):1–13.

Source: PubMed

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