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Postoperative cognitive dysfunction (pocd) in the (1)

General anaesthesia or regional anesthesia for elderly patients, which one better

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Postoperative cognitive dysfunction (pocd) in the (1)

  1. 1. Postoperative Cognitive Dysfunction (POCD) in the elderly By Ajay Moderator: Dr YOGA
  2. 2. POCD in the Elderly Changes in personality Changes in social integration Changes in cognitive powers and skills
  3. 3. Incidence Seymour ’86 Williams’92 Linn ’53 Francis’90 General Surgery Ortho Cataract Medical Hospitalization 10-15% (All patients 5-10%) 28-60% 1-3% 25-50%
  4. 4. History 1955,Bedford 1961,Simpson 1967,Blundell 1970,Finnish study recommended to confine operations to necessary cases concluded that anaesthesia had no effect and recorded benefits of surgery. believed anaesthetic drugs, fever etc caused POCD showed deterioration in 8% of elderly patients
  5. 5. Why does POCD occur? Physiologic effects of the anaesthetics: hyperventilation, hypotension or hypoxia Role of catecholamines or cholinergic transmission Genetic markers from dementia studies
  6. 6. Is POCD caused by GA or Regional? Study n Operation Age (yrs) POCD Difference Hole’80 60 THR 56-84 Yes Yes Kaarh’82 60 CAT >65 Yes Yes Riis ‘83 30 THR >60 Yes No Bigler’85 40 Hip >60 No No Chung’87 44 TURP 60-93 Yes Yes Hughes’88 30 THR 50-80 Yes Yes Ghonei’88 105 Joint 25-86 Slight No Asbjer’89 40 TURP 60-80 Yes No Jones’90 146 THR/TKR >60 No No Nielson’90 60 TKR 60-86 No No Camp ‘93 169 CAT 65-98 No No Willia’96 262 TKR >40 Yes No
  7. 7. Does GA per se cause POCD? • Subtle changes in all ages • Larger deficits with surgery of shorter duration Study n Operation Age(Yrs) Effects Smith ‘86 85 Ortho/Gynae./General 50-69 Yes Chung ‘90 40 Cholecystectomy 25-83 Yes Smith ‘91 112 TURP 48-88 Yes Tzabar 54 General 19-70 Yes
  8. 8. POCD in cardiac surgery Study n Surgery Age(yrs) Short-term Long-term Savageau’82 245 CABG/Valve 25-69 28% 24% Shaw’87 312 CABG 31-70 Yes NA Townes’89 90 CABG 40-59 Yes 11-31% McKhann’97 172 CABG 41-86 9-30% 11-33%
  9. 9. POCD in cardiac surgery Limited auto-regulatory capacity Hypothermia Intraoperative hypotension Loss of pulsatile flow Macro or micro-embolization Particulate cellular aggregates
  10. 10. Common drugs causing POCD Minor Tranquilizers Anti -hypertensives Diuretics Beta blockers Major Tranquilizer Analgesics Others Diazepam Methyldopa Hydrochlor- thiazide Propranolol Haloperidol Acetyl salicylic acid Cimetidine Flurazepam Reserpine Thorazine Meperidine Insulin Meprobamate Thioridazine Amoxapine Oxazepam Amantidine Chlorazepate
  11. 11. Summing up the aetiologic factors Preoperative Intraoperative Postoperative Physiologic and Pathologic Type of surgery Hypoxia Drugs Duration of surgery Hypocarbia Endocrine and metabolic Anaesthetic drugs Pain Mental status Type of anaesthesia Sepsis Sex Complications during surgery Electrolyte or metabolic
  12. 12. Diagnosis
  13. 13. Diagnosis
  14. 14. Prevention Preoperative Intraoperative Postoperative Detailed history of drugs Adequate oxygenation and perfusion Treat pain Evaluation of medical problems Correct the electrolyte imbalance Reassure patient and family Detections of sensory or perceptual deficits Adjust drug doses Keep patient informed and oriented Mental preparation prior to surgery Minimize the variety of drugs Quite surrounding Neuropsychologic testing Avoid atropine, flurazepam, scopolamine Well-lit cheerful room
  15. 15. Management Manage with extra vigilance Delirium may signal onset of pneumonia, sepsis, MI Reduce or stop risk associated drugs Haloperidol- the drug of choice ; Droperidol; Chlorpromazine Diazepam-useful in delirium tremens Thiamine-Korsakoff’s psychosis Avoid muscle relaxants or physical restraints; may need ABD control Psychiatric or psychological referral Physiotherapy and occupational therapy
  16. 16. References C. Dodds and J.Allision. Postoperative deficit in the elderly surgical patient.BJA 1998 Smita S. Parikh and Frances Chung.Postoperative Delirium in the Elderly.Anesth Anal 1995 Khwaja et al.Preoperative Factors Associated with Postoperative Changes in Confusion Assessment.Anesth Anal 2002
  17. 17. Thank you very much!