is postoperative cognitive dysfunction preventable in ...€¦ · decline function of brain and...

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Is Postoperative

cognitive dysfunction preventable in elderly ?

Roman Záhorec

2.dpt. Anesthesiology and Intensive Medicine,

Medical School , St. Elizabeths Cancer Institute

Comenius University , Bratislava

Decline function of brain and other organs with advanced age Brown E 2013, Rivera R, Anesthesiology 2009, vol.110,

Decreased neurotransmitter

synthesis

Mitochondrial ff. Decline

Loss of dendritic connections

Loss of cerebral mass

Decreased dynamics of

spines, microglia ff.

Seniors need less anesthetics

and easy enter burst suppression

Long-term survival after anesthesia in seniors . Robinson , Ann Surg 2009, 250(3): 449-458.

6-month mortality :

POD and POCD

Severe anemia,

hypoalbuminemia

Functional disability

and immobility - ADL,

Comorbidities severity

POCD definition and clinical dg.

Long lasting deficites of neuropsychological functions

Memory short-term,

Concentration, attention decline

Instrumental activity decreased

Mood and temperament changes

Battery of neuropsychological tests, writing, painting. (MMSE, CAM, PQRS,RASS)

Steinmetz J et al, Anesthesiology 2009

Predisposing and precipitating factors

Anxiety, fear, stress,

Sleep deprivation,

Depth of anesthesia,

Benzodiazepins,

Hypotension, Hypoxia

Surgical stress, SIRS

Infection, Inflammation

AGE, Dementia,

Stroke/TIA, Frailty

Immobility, Physical

Restrain, Co-morbidity

Hypertension,

Malnutrition

Enviroment ICU/ward

•PAIN

•ANXIETY •Hypothermia

• Hypothalamus • ANS

• Catecholamines

•Cortisol •Glucagon •GH , AVP,

Adrenomedulin

• IL-1,2,6 •TNF-a • Acute

Phase • SIRS

systemic

inflammatory

Reaction

1.

3.

POD § POCD

SIRS

STRESS

Pathophysiology and mechansims of POCD Cibelli AoN 2010, Degos V., Anesthesiology 2013

ANAESTHESIA

Anesthetics -neuromediators, brain injury

due to hypotension/hypoperfusion, neuroinflammation

SURGICAL

STRESS and

SURGICAL SIRS

PT.

PREDISPOSITION

AGE, FRAILTY,

Inflammation subclin.

Dementia, Stroke/TIA

ICU enviroment, noise,

Alarms, Light,sleep depriv.

Iatrogenic behaviour

POCD lasting more than

3 months

Depths of anesthesia

BIS < 40 more than 1 h.

Hypotension sAP< 90

more than 30 minutes

Increased mortality Social support

Impaired QoL

Labor activity,

Leaving work

RISK of POCD . Long-term consequences of POCD

Steinmetz J et al. , Anesthesiology 2009

Increased

mortality

in 1 year

Social

dependency

Impaired

Quality of Life

Decline

instrumental

activities

Mood §

temperament

Changes

Risk of leaving

work ability

Saczynski J., NEJM 2012, 347 POD § POCD is a dynamic

and complex neuropsycholog. process

Royse CF , PQRS , Anesthesiology 2010, 113(4): 892-905

Royse CF , PQRS , Anesthesiology 2010, 113(4): 892-905

Risk and Precipitating factors of POCD

in perioperative period

Infection / chronic

Inflammation Prevention of

Infections, Modulat.

Deep

anesthesia

BIS < 40

Avoid BIS < 40,

meas. depth.Anesth

Hypoxia,

ischemia Avoid hypoxemia,

Normotension dAP

Dehydratation

Hypotension Crystalloids ,

Normotension

Hypoglycaemia

Hypoalbuminemi Glucose/glycemi

Nutriton/antioxid

.

Avoid benzodiazepins Benzodiazepins

Drugs and supplements for POCD § POD prevention ?

Dexmedetomidin - Vegos 2013, Riker 2009, Rukonen 2009,

Pandharipande PP JAMA 2007.

Antipsychotic drugs – haloperidol, risperidon, Kaneko

1999, Kalisvaart 2005, Prakanattane 2007

Ketamin low dose 0,5 mg/kg g.a. induction Hudetz 2009

Melatonin , in premedication Torok , 2014

Vitamin D supplemention - Morandi ,2013

Multicomponent intervention - Lunstrom 2007, Zhang 2013

Light sedation during spinal anesthesia BIS80 Sieber

2010

Is POCD preventable ?

Preventable

Multicomponent

strategy

In elderly

Considering role of

INFLAMMATION

AVOID MAJOR

SURGERY

BEHAVIOURAL

SOCIAL SUPPORT,

EXERCISE,

ACTIVITY

Prevention strategies of POCD Modulation inflammation § Avoid major surgery

Avoid /treat infection

Modulation of inflamm. Neuroinflammation

Anaesthesia managm. Moderate anaesthesia BIS 40-50, SaO2 95%

Prevent hypotension, hypoxemia

Miniinvasive surgery

Invasive radiology

Surgery under locoregional anaesthesia

Modulate surgical SIRS and surgical stress

Communicate before surgery and anaesth.

Hospital Elder Life Program

•Increased physical

and psych. Activity

•Exercise

•Nutrition and drink

•Psychologic supp.

•Family, friends, relat

communication

THANK YOU for ATTENTION ...