October 13, 2016

Anesthesia and Postoperative Cognitive Decline (PCOD) in Elderly Patients

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By  Jill S. Detty Oswaks, DNSc, CRNA, and Lorena Thompson, DNP, CRNA

Over the years, anesthesia care and safety has improved, expanding anesthesia delivery to all age groups with a wide range of health needs. Parallel to the increased safety using newer anesthetic agents and technology, scientific knowledge is emerging on the effects of stress and anesthesia on long term health.  The baby boom generation will enter retirement with a greater projected lifespan than their parents and with greater health issues.4 Anesthesia providers and patients, aged 60 and older, must be aware of the potential effects of anesthesia on long term health.

Age, which affects almost every organ system, is strongly correlated with diseases, need for hospitalization and length of stay, injuries, and adverse reactions to medications1. The associated risks for increased morbidity and mortality parallel an increase in surgeries in the aging population.

A major public health concern is post-operative cognitive decline (POCD) in the elderly. The study of POCD is to determine if a link between perioperative care and POCD exists and strategies to prevent its development.  Postoperative cognitive decline is defined as a drop in cognitive performance on neuropsychological tests postoperatively as compared to preoperative performance2. Unfortunately, diagnosis can only occur in individuals who have undergone preoperative neuropsychological testing.   The implications of POCD are greater than just cognitive decline and include increased morbidity and mortality, decreased quality of life, and earlier exit from the workforce2.

Like any public health concern there are modifiable and non-modifiable risk factors for POCD.   The non-modifiable risk factors include increased age, fewer years of previous education, type of surgery, genetic risk, preoperative renal insufficiency, previous stroke, and lower performance on preoperative neuropsychological tests2. Patients’ and anesthesia’s focus is on the modifiable risk factors.

Individuals can contribute to improved postoperative outcomes through smoking cessation, controlling diabetes, and physical exercise2,3. While aging is associated with decreased physiologic reserve, this is worsened by sedentary lifestyles3. Physical exercise is associated with increasing physiologic reserve and adaptation to stress. Improved physical reserve is associated with decreased psychological stress, better healing, faster return to preoperative physiologic baseline and decreased postoperative pain3.

Anesthesia providers have an ever increasing awareness of monitoring anesthetic depth, medications and adverse effects in the elderly and anesthetic management strategies to improve outcomes. Concerted efforts between the aging patient and anesthesia can decrease modifiable risks and decrease the risk of POCD.

 

References:

  1. Alvis, B.D., & Hughes, C.G. (2015). Physiology considerations in geriatric patients.  Anesthesiology Clinics, 33, 447–456. doi: 10.1016/j.anclin.2015.05.003.
  2. Berger, M., Nadler, J., Browndyke, J., Terrando, N., Ponnusamy, V., Cohen, H.J., Whitson, H.E., & Mathew, J.P. (2015). Postoperative cognitive dysfunction: Minding the gaps in our knowledge of a common postoperative complication in the elderly. Anesthesiology Clinics, 33, 517–550. doi: 10.1016/j.anclin.2015.05.008
  3. Carli, F. & Scheede-Bergdahl (2015). Prehabilitation to enhance perioperative care.  Anesthesiology Clinics 33, 17–33. doi:10.1016/j.anclin.2014.11.002
  4. King, D. E., Matheson, E., Chirina, S., & Shankar, A. (2013). The status of baby boomer’s health in the United States: The healthiest generation? JAMA Internal Medicine, 173(5), 385-386. Jill S. Detty Oswaks, DNSc, CRNA, Lorena Thompson, DNP, CRNA