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.

1. POSTOPERATIVE COGNITIVE
DYSFUNCTION
What should we know?
Siti Chasnak Saleh
Airlangga Univ./Soetomo Hospt.
Surabaya
03/08/16 1

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. 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
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
0
5
10
15
20
25
30
P
e
r
c
e
n
t
a
g
e
(
%
)
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. 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. 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. Predictors of POCD:
3 Months After Surgery
NS0.046 History of MI
NS0.021 Baseline Co-morbidity
NS0.009 ASA Physical Status
NS0.003 History of Stroke
2.51 (p=0.057)0.001 Age
0.86 (p=0.028) < 0.001 Years of Education
NS0.028 NYHA Status
NSNS Anesthesia Time
NSNS Baseline MMSE
NSNS Gender
NSNS Surgery Type
Multivariate Odds Ratio Univariate P value Risk Factors for POCD
Multivariate c-statistic = 0.671 (p = 0.003)
Monk et al. Anesthesiology 2001; 95: A-50

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. Continuum from Normal Aging through
Mild Cognitive Impairment to Dementia
Mild cognitive impairment
Dementia
Age
F
u
n
c
t
i
o
n
Normal Aging
03/08/16 10

11. Threshold Theory for Cognitive Decline
LesionLesion
LesionLesion
Protective
Factor
Case A Case B
B
r
a
i
n

R
e
s
e
r
v
e

C
a
p
a
c
i
t
y
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. 03/08/16 12

13. 03/08/16 13
Mayo Clin Proc. 2011;86(6):885-893
Pathogenesis of cognitive decline

14. Proposed Mechanisms for Neuroinflammation
and POCD
J Anesth Perioper Med
2014; 1: 97-103.
03/08/16 14

15. 03/08/16 15
Eckenhoff R, Prog Neuro-Psychopharm & Bio Psych, 2012

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. 03/08/16 17
Rossi et al .Anesth Analg 2014;119:947–55)

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. 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. 03/08/16 20