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Postoperative Cognitive Dysfunction

  • Geriatric Anesthesia (S Akhtar, Section Editor)
  • Published:
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Abstract

Purpose of review

Postoperative cognitive dysfunction (POCD) is a poorly defined syndrome to describe cognitive impairment in patients following anaesthesia and surgery. This narrative POCD review outlines the relevant literature from animal and clinical studies published within the last 5 years with a focus on elderly patients.

Recent findings

Increasing age is a well-recognised risk factor for POCD, and in some patients, the resulting cognitive impairment will persist. The association with postoperative delirium is unclear. The evidence supports that neuroinflammation as a result of surgical stress is a key factor in POCD, and patients with pre-existing cognitive impairment are particularly at risk. Clinical research consists of conflicting results with regard to the anaesthetic technique and small hypothesis-generating single-site studies regarding biomarkers and potential therapies.

Summary

A definition and diagnostic criteria for POCD are urgently needed to inform research into the pathophysiology, identification of patients at risk and anaesthetic management designed to improve patient outcomes. We conclude with a recommendation for current clinical practice.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bedford PD. Adverse cerebral effects of anaesthesia on old people. Lancet. 1955;266:259–64.

    Article  Google Scholar 

  2. Moller JT, Cluitmans P, Rasmussen LS, et al. Long-term postoperative cognitive dysfunction in the elderly. Lancet. 1998;351:857–61.

    Article  CAS  PubMed  Google Scholar 

  3. Griffiths R, Beech F, Brown A, et al. Peri-operative care of the elderly 2014: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2014;69:81–98.

    Article  PubMed  Google Scholar 

  4. Khalil S Roussel J, Schubert A, Emory L. Postoperative cognitive dysfunction: an updated review. J Neurol Neurophsysiol. 2015; 290.

  5. O’Brien H, Mohan H, Hare CO, et al. Mind over matter? The hidden epidemic of cognitive dysfunction in the older surgical patient. Ann Surg. 2017;265:677–91.

    Article  Google Scholar 

  6. Feinkohl I, Winterer G, Pischon T. Hypertension and risk of post-operative cognitive dysfunction (POCD): a systematic review and meta-analysis. Clin Pract Epidemiol Ment Health. 2017;13:27–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  7. Kline RP, Pirraglia E, Cheng H, et al. Surgery and brain atrophy in cognitively normal elderly subjects and subjects diagnosed with mild cognitive impairment. Anesthesiology. 2012;116:603–12.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Rundshagen I. Postoperative cognitive dysfunction. Dtsch Arztebl Int. 2014;111:119–25.

    PubMed  PubMed Central  Google Scholar 

  9. Berger M, Eckenhoff R. ASA Brain Health Initiative: the science behind the scene. ASA Monitor. 2016;80:12–4.

    Google Scholar 

  10. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (5th ed.) Washington DC, (2013).

  11. ICD-10 Version, Delirium, not induced by alcohol and other psychoactive substances. V F05, (2010).

  12. Silbert B, Evered L, Scott DA, et al. Preexisting cognitive impairment is associated with postoperative cognitive dysfunction after hip joint replacement surgery. Anesthesiology. 2015;122:1224–34.

    Article  PubMed  Google Scholar 

  13. Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med. 2013;369:1306–16.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Mehta S, Cook D, Devlin JW, et al. Prevalence, risk factors, and outcomes of delirium in mechanically ventilated adults. Crit Care Med. 2015;43:557–66.

    Article  PubMed  Google Scholar 

  15. •• Terrando N, Eriksson LI, Eckenhoff RG. Perioperative neurotoxicity in the elderly: summary of the 4th International Workshop. Anesth Analg. 2015;120:649–52. A group of scientists and physicians met in Stockholm for a full day of presentations and interactive discussions. This article summarizes the discussion; highlighting progress, challenges, and new directions

    Article  PubMed  Google Scholar 

  16. Browndyke JN, Berger M, Harshbarger T, et al. Resting-state functional connectivity and cognition after major cardiac surgery in older adults without preoperative cognitive impairment: preliminary findings. J Am Geriatr Soc. 2017;65:e6.

    Article  PubMed  Google Scholar 

  17. Ni C, Xu T, Li N, et al. Cerebral oxygenation saturation after multiple perioperative influential factors predicts the occurrence of postoperative cognitive dysfunction. BMC Anesthesiol. 2015;15:156.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Vacas S, Degos V, Feng X, Maze M. The neuroinflammatory response of postoperative cognitive decline. Br Med Bull. 2013;106:161–78.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  19. Feng X, Valdearcos M, Uchida Y, et al. Microglia mediate postoperative hippocampal inflammation and cognitive decline in mice. JCI Insight. 2017;2:e91229.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Forsberg A, Cervenka S, Jonsson Fagerlund M, et al. The immune response of the human brain to abdominal surgery. Ann Neurol. 2017;81:572–82.

    Article  CAS  PubMed  Google Scholar 

  21. • Kline R, Wong E, Haile M, et al. Peri-operative inflammatory cytokines in plasma of the elderly correlate in prospective study with postoperative changes in cognitive test scores. Int J Anesthesiol Res. 2016;4:313–21. A well conducted and reported trial looking at long term POCD at 6 months including a mechanistic element

    CAS  PubMed  PubMed Central  Google Scholar 

  22. Zheng YB, Ruan M, Fu JX, et al. Postoperative 8-iso-prostaglandin F2α plasma levels are associated with delirium and cognitive dysfunction in elderly patients after hip surgery. Clin Chim Acta. 2016;455:149–53.

    Article  CAS  PubMed  Google Scholar 

  23. Xie H, Huang D, Zhang S, et al. Relationships between adiponectin and matrix metalloproteinase-9 (MMP-9) serum levels and postoperative cognitive dysfunction in elderly patients after general anaesthesia. Aging Clin Exp Res. 2016;28:1075–9.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Wu XM, Xu WC, Yu YJ, et al. Postoperative serum thioredoxin concentrations correlate with delirium and cognitive dysfunction after hip fracture surgery in elderly patients. Clin Chim Acta. 2017;466:93–7.

    Article  CAS  PubMed  Google Scholar 

  25. Zhang Q, Li SZ, Feng CS, et al. Serum proteomics of early postoperative cognitive dysfunction in elderly patients. Chin Med J. 2012;125:2455–61.

    CAS  PubMed  Google Scholar 

  26. Avidan MS, Benzinger TL. Surgery and the plastic brain. Anesthesiology. 2012;116:510–2.

    Article  PubMed  Google Scholar 

  27. Kavanagh T, Buggy DJ. Can anaesthetic technique effect postoperative outcome? Curr Opin Anaesthesiol. 2012;25:185–98.

    Article  CAS  PubMed  Google Scholar 

  28. • Radtke FM, Franck M, Lendner J, et al. Monitoring depth of anaesthesia in a randomized trial decreases the rate of postoperative delirium but not postoperative cognitive dysfunction. Br J Anaesth. 2013;110:i98–105. A large trial that reports on the incidence of POCD as well as the impact of BIS monitoring on anaesthetic exposure

    Article  CAS  PubMed  Google Scholar 

  29. Li Y, He R, Chen S, Qu Y. Effect of dexmedetomidine on early postoperative cognitive dysfunction and peri-operative inflammation in elderly patients undergoing laparoscopic cholecystectomy. Exp Ther Med. 2015;10:1635–42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. •• Bilotta F, Stazi E, Zlotnik A, et al. Neuroprotective effects of intravenous anaesthetics: a new critical perspective. Curr Pharm Des. 2014;20:5469–75. A comprehensive review of the current evidence for using intravenous anaesthetics when neuroprotection is a priority

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Lui LL, Ning B, Lu HW. Effects of CO2 pneumoperitoneum on the cognitive function of patients undergoing gynecologic laparoscopy. Gyencol Obstet Invest. 2016;81:90–5.

    Article  Google Scholar 

  32. Sprung J, Roberts RO, Knopman DS, et al. Association of mild cognitive impairment with exposure to general anaesthesia for surgical and nonsurgical procedures: a population based study. Mayo Clin Proc. 2016;91:208–17.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Steinmetz J, Siersma V, Kessing LV, Rasmussen LS, ISCOPD Group. Is postoperative cognitive dysfunction a risk factor for dementia? A cohort follow-up study. Br J Anaesth. 2013;110:i92–7.

    Article  PubMed  Google Scholar 

  34. • Patel D, Lunn AD, Smith AD, et al. Cognitive decline in the elderly after surgery and anaesthesia: results from the Oxford Project to Investigate Memory and Ageing (OPTIMA) cohort. Anaesthesia. 2016;71:1144–52. Examples of the use of an existing database to explore the possible modifiable factors involved in cognitive impairment and inform future research

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  35. Docherty AB, Shenkin SD. Cognitive decline after surgery and anaesthesia: correlation does not mean causation. Anaesthesia. 2016;71:1131–5.

    Article  CAS  PubMed  Google Scholar 

  36. Krenk L, Kehlet H, Hansen B, et al. Cognitive dysfunction after fast-track hip and knee replacement. Anesth Analg. 2014;118:1034–40.

    Article  CAS  PubMed  Google Scholar 

  37. Saleh A, Tang GX, Hadi SM, et al. Preoperative cognitive intervention reduces cognitive dysfunction in elderly patients after gastrointestinal surgery: a randomised controlled trial. Med Sci Monit. 2015;21:798–805.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Yang N, Li L, Li Z, et al. Protective effect of dapsone on cognitive impairment induced by propofol involves hippocampal autophagy. Neurosci Lett. 2017;649:85–92.

    Article  CAS  PubMed  Google Scholar 

  39. Zhu YZ, Yao R, Zhang Z, et al. Parecoxib prevents early postoperative cognitive dysfunction in elderly patients undergoing total knee arthroplasty. Medicine (Baltimore). 2016;95:e4082.

    Article  CAS  Google Scholar 

  40. Skvarc DR, Dean OM, Bryne LK, et al. The post-anaesthesia N-acetylcysteine cognitive evaluation (PANACEA) trial: study protocol for a randomised controlled trial. Trials. 2016;17:395.

    Article  PubMed  PubMed Central  Google Scholar 

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Author information

Authors and Affiliations

  1. Intensive Care Unit, Watford General Hospital, Vicarage Road, Watford, WD18 0HB, UK

    Valerie J. Page

  2. Faculty of Medicine, Imperial College, South Kensington Campus, London, SW7 2AZ, UK

    Valerie J. Page

  3. University Hospitals Bristol NHS Trust, Marlborough Street, Bristol, BS1 3NU, UK

    Fiona C. Oglesby

  4. North Bristol NHS Trust, Southmead Hospital, Southmead Road, Westbury-on-Trym, Bristol, BS105NB, UK

    Richard A. Armstrong

Authors
  1. Valerie J. Page
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  2. Fiona C. Oglesby
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  3. Richard A. Armstrong
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Corresponding author

Correspondence to Valerie J. Page.

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Conflict of Interest

Valerie J. Page has received research funding from the National Institute for Health Research (NIHR) through a Research for Patient Benefit (RfPB) grant stream, has received honoraria from Orion, UK, and has received editorial fees from BMJ.

Fiona C. Oglesby declares that she has no conflict of interest.

Richard A. Armstrong declares that he has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Geriatric Anesthesia

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Page, V.J., Oglesby, F.C. & Armstrong, R.A. Postoperative Cognitive Dysfunction. Curr Anesthesiol Rep 7, 380–386 (2017). https://doi.org/10.1007/s40140-017-0238-1

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  • DOI: https://doi.org/10.1007/s40140-017-0238-1

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