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General anaesthesia or regional anesthesia for elderly patients, which one better
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Postoperative Cognitive Dysfunction (POCD) in the elderly
By AjayModerator: Dr YOGA
POCD in the ElderlyChanges in personality
Changes in social integration
Changes in cognitive powers and skills
IncidenceSeymour ’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%
History1955,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
Why does POCD occur?Physiologic effects of the anaesthetics: hyperventilation, hypotension or hypoxia
Role of catecholamines or cholinergic transmission
Genetic markers from dementia studies
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
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
POCD in cardiac surgeryStudy 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%
POCD in cardiac surgeryLimited auto-regulatory capacity
Hypothermia
Intraoperative hypotension
Loss of pulsatile flow
Macro or micro-embolization
Particulate cellular aggregates
Common drugs causing POCDMinorTranquilizers
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
Summing up the aetiologic factorsPreoperative 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
Diagnosis
Diagnosis
PreventionPreoperative 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
ManagementManage 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
ReferencesC. 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
Thank you very much!
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