postoperative cognitive impairment
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Introduction
- cognitive decline that involves selective attention, vigilance, perception, learning, memory, executive function, verbal & language abilities, emotion, visuospatial & visuomotor skills.
- occurs postoperativeltin the absence of cranial trauma or other brain injuries
Etiology
- preexisting cognitive impairment, especially working memory impairment is associated with poor behavioral functional capacity 3 months after cardiac surgery[3]
- postoperative delirium is associated with persistent cognitive impairment
- anesthesia[4]
- depth of general anesthesia potentially modifiable factor
- no difference in general anesthesia vs regional anesthesia
- inhalation anesthesia more likely implicated than intravenous anesthesia
- pharmaceuticals
- pain management
- patient-controlled postoperative analgesia independently increases the risk vs oral postoperative analgesia[7]
- pregabalin, given for postoperative pain, associated with adverse effects on cognition (spatial working memory & executive function)[5]
- persistent pain can result in cognitive impairment, inattention, memory loss, & information processing.
- pain management
- high-risk surgeries
- inhalation anesthesia with isoflurane or sevoflurane confers higher risk than intravenous anesthesia with propofol
Epidemiology
- common in early postoperative period in all age groups
- elderly more commonly suffer long-term cognitive impairment
- 65% of elderly (>= 65 years) experience postoperative delirium & 10% develop long-term cognitive decline after noncardiac surgery[6]
- prevalence of 37% in young adults to 42% in older adults[7]
- old age, less education, previous stroke predict long-term cognitive impairment after non-cardiac surgery
Pathology
- neuroinflammation may occur as a result of perioperative stress[6]
- vascular disorders may contribute to postoperative cognitive impairment[6]
- acceleration of neurocognitive decline may occur in patients with a previously undiagnosed neurodegenerative disorder, mild cognitive impairment or preclinical dementia[6]
- 7% of elderly (>= 65 years) who undergo non-cardiac surgery suffer covert stroke with increased risk of postoperative delirium & long-term cognitive deficits[6]
Clinical manifestations
- subtle, delayed decline in cognitive function
- cognitive impairment may be noted in one or more domains
- executive function is most commonly affected
- prolonged cognitive decline can last for weeks, months, or even years[7]
- most patients return to preoperative cognitive baseline within 3 months
- report of postoperative cognitive impairment for up to 5 years[4]
Diagnostic procedures
- neuropsychiatric testing before & after surgery for definitive diagnosis
Complications
- postoperative cognitive impairment may be associated with increased risk of chronic postoperative pain[2]
- decrease in quality of life, loss of function, & increased mortality[6]
Differential diagnosis
- postoperative delirium[10][11][12]
- acute, fluctuating disturbance
- typically develops within 1-3 days after surgery
- characterized by inattention, disorganized thinking, & altered consciousness
- deafness
- dementia
- amnesia[7]
Management
- in most cases, cognition returns to preoperative baseline within a few months
- some cases of postoperative cognitive impairment may last for years
- there is no pharmaceutical treatment for postoperative cognitive impairment
- family-involvement reduces postoperative delirium
- social interactions play an important role in cognitive health of the elderly
- preoperative measures may provide some prophylaxis
- preoperative screening for frailty & dementia, geriatric consultation for elderly
- preoperative cognitive assessment is the best predictor of risk for postoperative delirium thus risk of peristent cognitive dysfunction
- preoperative physical activity, tobacco cessation, nutrition, & management of hypertension & diabetes improves postoperative outcomes
- preoperative cognitive exercises targeting memory, speed, attention, flexibility, & problem-solving reduces postoperative delirium[6]
- perioperative period avoidance of benzodiazepines, centrally-acting cholinergics, meperidine, phenothiazines, & antipsychotics in the elderly (>= 65 years)[6]
More general terms
Additional terms
References
- ↑ Monk TC et al, Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiolgy 2008, 108:18 PMID: https://pubmed.ncbi.nlm.nih.gov/18156878
- ↑ 2.0 2.1 Attal N et al. Does cognitive functioning predict chronic pain? Results from a prospective surgical cohort. Brain 2014 Mar; 137:904. <PubMed> PMID: https://pubmed.ncbi.nlm.nih.gov/24441173 <Internet> http://brain.oxfordjournals.org/content/137/3/904
- ↑ 3.0 3.1 Messerotti Benvenuti S, Patron E, Zanatta P et al Preexisting cognitive status is associated with reduced behavioral functional capacity in patients 3 months after cardiac surgery: an extension study. Gen Hosp Psychiatry. 2014 Mar 5. pii: S0163-8343(14)00059-0 PMID: https://pubmed.ncbi.nlm.nih.gov/24684903
- ↑ 4.0 4.1 4.2 Geriatric Review Syllabus, 8th edition (GRS8) Durso SC and Sullivan GN (eds) American Geriatrics Society, 2013
Geriatric Review Syllabus, 10th edition (GRS10) Harper GM, Lyons WL, Potter JF (eds) American Geriatrics Society, 2019 - ↑ 5.0 5.1 Myhre M, Jacobsen HB, Andersson S, Stubhaug A. Cognitive effects of perioperative pregabalin: Secondary exploratory analysis of a randomized placebo-controlled study. Anesthesiology 2019 Jan; 130:63 PMID: https://pubmed.ncbi.nlm.nih.gov/30335626
- ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 6.8 Vacas S, Cole DJ, Cannesson M Cognitive Decline Associated With Anesthesia and Surgery in Older Patients. JAMA. Published online August 2, 2021 PMID: https://pubmed.ncbi.nlm.nih.gov/34338712 https://jamanetwork.com/journals/jama/fullarticle/2782851
- ↑ 7.0 7.1 7.2 7.3 7.4 Spriano P What Do We Know About Postoperative Cognitive Dysfunction? Medscape. Sept 9, 2024 https://www.medscape.com/viewarticle/what-do-we-know-about-postoperative-cognitive-dysfunction-2024a1000g9b
- ↑ Kong H, Xu LM, Wang DX Perioperative neurocognitive disorders: A narrative review focusing on diagnosis, prevention, and treatment. CNS Neurosci Ther. 2022 Aug;28(8):1147-1167 PMID: https://pubmed.ncbi.nlm.nih.gov/35652170 PMCID: PMC925375
- ↑ Brodier EA, Cibelli M. Postoperative cognitive dysfunction in clinical practice. BJA Educ. 2021 Feb;21(2):75-82. PMID: https://pubmed.ncbi.nlm.nih.gov/33889433 PMCID: PMC7810820 Free PMC article. Review. https://pmc.ncbi.nlm.nih.gov/articles/PMC7810820/
- ↑ 10.0 10.1 Daiello LA, Racine AM, Yun Gou R et al Postoperative Delirium and Postoperative Cognitive Dysfunction: Overlap and Divergence. Anesthesiology. 2019 Sep;131(3):477-491. PMID: https://pubmed.ncbi.nlm.nih.gov/31166241 PMCID: PMC6692220 Free PMC article. https://pmc.ncbi.nlm.nih.gov/articles/PMC6692220/
- ↑ 11.0 11.1 Cascella M, Muzio MR, Bimonte S, Cuomo A, Jakobsson JG. Postoperative delirium and postoperative cognitive dysfunction: updates in pathophysiology, potential translational approaches to clinical practice and further research perspectives. Minerva Anestesiol. 2018 Feb;84(2):246-260. PMID: https://pubmed.ncbi.nlm.nih.gov/28984099 Free article. https://www.minervamedica.it/en/journals/minerva-anestesiologica/article.php?cod=R02Y2018N02A0246
- ↑ 12.0 12.1 Krenk L, Rasmussen LS. Postoperative delirium and postoperative cognitive dysfunction in the elderly
what are the differences? Minerva Anestesiol. 2011 Jul;77(7):742-9. PMID: https://pubmed.ncbi.nlm.nih.gov/21709661 Free article. Review. https://www.minervamedica.it/en/journals/minerva-anestesiologica/article.php?cod=R02Y2011N07A0742