Postoperatives kognitives Defizit bei alten Patienten

Zusammenfassung

Postoperative kognitive Defizite treten vor allem bei älteren Patienten nach großen chirurgischen Eingriffen auf und beeinflussen die Morbidität und Mortalität dieser Patienten. Die Diagnose kann durch klinische Beobachtung und Durchführung neuropsychologischer Tests gestellt werden. Da bisher keine medikamentösen Therapieansätze der postoperativen kognitiven Störungen existieren, ist bei Risikopatienten die perioperative Durchführung präventiver Maßnahmen essenziell.

Abstract

Postoperative congnitive dysfunction occurs in geriatric patients after major operations and influences morbidity and mortality of these patients. Clinical observations and neuropsychological tests can be used to diagnose cognitive disorders after an operation. Until today no specific medical treatment is known for the therapy of cognitive dysfunctions after an operation and, therefore, in high risk patients perioperative preventive measures is the only way to decrease the incidence and extend of this disease.

Schlüsselwörter:

postoperatives kognitives Defizit - geriatrischer Patient - Prävention - Anästhesie

Key words:

postoperative cognitive dysfunction - geriatric patient - prevention - anaesthesia

Kernaussagen

• Das postoperative kognitive Defizit ist vom postoperativen Delir zu unterscheiden.

• Die Morbidität und Mortalität geriatrischer Patienten wird durch das postoperative Auftreten von Kognitionsstörungen negativ beeinflusst.

• Es existieren patientenbezogene, operative und medikamentöse Risikofaktoren, die das Auftreten von postoperativen kognitiven Dysfunktionen begünstigen.

• Die Diagnostik von postoperativen kognitiven Defiziten ist diffizil und kann mittels genauer klinischer Beobachtung oder durch spezifische Tests durchgeführt werden.

• Es existieren keine Medikamente die gezielt postoperative Kognitionsstörungen therapieren können.

• Das Risiko des älteren Patienten, eine kognitive Dysfunktion zu entwickeln, sollte präoperativ abgeschätzt werden.

• Bei Patienten mit einem erhöhten Risiko für kognitive Störungen nach einer Operation müssen präventive Maßnahmen durchgeführt werden.

• Inwieweit der Einsatz von Dopaminrezeptorantagonisten, neueren atypischen Antipsychotika und Cholinesterasehemmern gerechtfertigt ist, kann noch nicht abschließend beurteilt werden.

Literatur

• 1 Wacker P, Nunes P, Cabrita H. et al. . Post–operative delirium is associated with poor cognitive outcome and dementia.  Dement Geriatr Cogn Disord. 2006;  21 221-227
• 2 Bedford P, Leeds M.. Adverse cerebral effects of anaesthesia on old people.  Lancet. 1955;  269 259-263
• 3 Silverstein J, Timberger M, Reich D. et al. . Central nervous system dysfunction after noncardiac surgery and anesthesia in the eldery.  Anesthesiology. 2007;  106 622-628
• 4 Rogers M, Liang M, Daltroy L. et al. . Delirium after elective ortopedic surgery: risk factors and natural history.  Int J Psychiatry Med. 1989;  19 109-121
• 5 Perry E.. Cholinergic mechanisms and cognitive decline.  Eur J Anaesth. 1998;  15 768-773
• 6 Tune L, Carr S, Cooper T. et al. . Association of anticholinergic activity of prescribed medications with postoperative delirium.  J Neuropsychiatry Clin Neurosci. 1993;  5 208-210
• 7 Tune L, Holland A, Folstein M. et al. . Association of postoperative delirium with raised serum levels of anticholinergic drugs.  Lancet. 1981;  318 651-653
• 8 Bernhardi R, Ramirez G.. Microglia–astrocyte interaction. In AlzheimerŽs disease: friend or foes for the nervous system?.  Biol Res. 2001;  34 123-128
• 9 Tracey K.. Physiology and immunology of the cholinergic antiinflammatory pathway.  J Clin Invest. 2007;  117 289-296
• 10 McIntosh T, Bush H, Yeston N. et al. . Beta–endorphin, cortisol and postoperative delirium: a preliminary report.  Psychoneuroendocrinology. 1985;  10 303-313
• 11 Schmitt T, Pajonk F.. Postoperatives Delir beim Intensivpatienten.  Anaesthesist. 2008;  57 403-431
• 12 Perry E.. The cholinergic system in old age and AlzheimerŽs disease.  Age Ageing. 1980;  9 1-8
• 13 Thal L, Ferguson J, Mintzer J. et al. . A 24–week randomized trial of controlled–release physostigmine in patients with Alzheimer's disease.  Neurology. 1999;  52 1146-1152
• 14 Monk T, Weldon B, Gravan C. et al. . Predictors of cognitive dysfunction after major noncardiac surgery.  Anesthesiology. 2008;  108 18-30
• 15 Newman S, Stygall J, Hirani S. et al. . Postoperative cognitive dysfunction after noncardiac surgery.  Anesthesiology. 2007;  106 572-590
• 16 Moller J, Cluitmans P, Rasmussen L. et al. . Long–term postoperative cognitive dysfunction in the elderly; ISPOCD1 study.  Lancet. 1998;  351 857-861
• 17 Hudetz J, Iqlab Z, Gandhi S. et al. . Postoperative cognitive dysfunction in older patients with a history of alcohol abuse.  Anesthesiology. 2007;  106 423-430
• 18 Mare M, Cibelli M, Grocott H.. Taking the lead in research into postoperative cognitive dysfunction.  Anesthesiology. 2008;  108 1-2
• 19 Silverstein J, Steinmetz J, Reichenberg A. et al. . Postoperative cognitive dysfunction in patients with preoperative cognitive impairment.  Anesthesiology. 2007;  106 431-435
• 20 Ropacki S, Bert A, Ropacki M. et al. . The influence of congnitive reserve on neuropsychological functioning following coronary artery bypass grafting (CABG).  Arch Clin Neruopsychol. 2007;  22 73-85
• 21 Bruce A, Ritchie C, Blizard R. et al. . The incidence of delirium associated with orthopedic surgery: a meta–analytic review.  Int Psychogeriatr. 2007;  19 197-214
• 22 Böhner H, Schneider F, Stierstorfer A. et al. . Durchgangssyndrome nach gefäßchirurgischen Operationen.  Chirurg. 2000;  71 215-221
• 23 Benoit A, Campbell B, Tanner J. et al. . Risk factors and prevalence of perioperative cognitive dysfunction in abdominal aneurysm patients.  J Vasc Surg. 2005;  42 884-890
• 24 Rodriguez R, Tellier A, Grabowski J. et al. . Cognitive dysfunction after total knee arthroplasty – effects of intraoperative cerebral embolizattion and postoperative complications.  J Arthroplasty. 2005;  20 763-771
• 25 Newman M, Kirchner J, Phillips–Bute B. et al. . Longitudinal assessment of neurocognititve function after coronary–artery bypass surgery.  N Engl J Med. 2001;  344 395-402
• 26 Galanakis P, Bickel H, Gradinger R. et al. . Acute confusional state in the elderly following hip surgery: incidence, risk factors and compliations.  Int J Geriatr Psychiatry. 2001;  16 349-355
• 27 Vaurio L, Sands L, Wang Y. et al. . Postoperative delirium: the importance of pain and pain management.  Anesth Analg. 2006;  102 1267-1273
• 28 Praticò C, Quattrone D, Lucanto T. et al. . Drugs of anesthesia acting on central cholinergic system may cause post–operative cognitive dysfunction and delirium.  Medical Hypotheses. 2005;  65 972-982
• 29 Tassonyi E, Charpantier E, Muller D. et al. . The role of nicotinic acetylcholine receptors in the mechanism of anesthesia.  Brain Res Bull. 2002;  57 133-150
• 30 Bryson G, Wyand A.. Evidence–based clinical update: General anesthesia and the risk of delirium and postopreative cognitive dysfunction.  Can J Anesth. 2006;  53 669-677
• 31 Fong H, Sands L, Leung J.. The role of postoperative analgesia in delirium and cognitive decline in eldery patients: a systematic review.  Anesth Analg. 2006;  102 1255-1266
• 32 Marcantonio E, Juarez G, Goldman L. et al. . The relationship of postoperative delirium with psychoactive medications.  JAMA. 1994;  272 1518-1522
• 33 Moore A, OŽKeffe S.. Drug–induced cognitive impariment in the elderly.  Drug and Aging. 1999;  15 15-28
• 34 Price C, Garvan C, Monk T.. Type and severity of cognitive decline in older adults after noncardiac surgery.  Anesthesiology. 2008;  108 8-17
• 35 Priner M, Jourdain M, Bouche G. et al. . Usefulness of the short IQCODE for predicting postoperative delirium in elderly patients undergoing hip and knee replacement surgery.  Gerontology. 2008;  54 116-119
• 36 de Jonghe J, Kalisvaart K, Dijkstra M. et al. . Early symptoms in the prodromal phase of delirium: a prospective cohort study in elderly patients undergoing hip surgery.  Am J Geriatr Psychiatry. 2007;  15 112-121
• 37 Harari D, Hopper A, Dhesi J. et al. . Proactive care of older people undergoing surgery (ŽPOPSŽ): designing, embedding, evaluating and funding a comprehensive geriatric assessment service for older elective surgical patients.  Age Ageing. 2007;  36 190-196
• 38 Siddigi N, Stockdale R, Britton A, Holmes J.. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007
• 39 Marcantonio E, Flacker J, Wright R, Resnick N.. Reducing delirium after hip fracture: a randomized trial.  J Am Geriatr Soc. 2001;  49 516-522
• 40 Linsted U, Meyer O, Kropp P. et al. . Serum concentration of S–100 protein in assessment of cognitive dysfunction after general anesthesia in different types of surgery.  Acta Anaesthesiol Scand. 2002;  46 384-389
• 41 Rasmussen L, Christiansen M, Eliasen K. et al. . Biochemical markers for brain damage after cardiac surgery – time profile and correlation with cognitive dysfunction.  Acta Anaesthesiol Scand. 2002;  46 547-551
• 42 Schneemilch C.. Postoperatives kognitives Defizit: Prophylaxe, Therapie und Rehabilitation.  Journal für Anästhesie und Intensivbehandlung. 2004;  1 228-229
• 43 Lynch E, Lazor MG, Orav J. et al. . The impact of postoperative pain on the development of postoperative delirium.  Anesth Analg. 1998;  86 781-785
• 44 Kalisvaart K, De Jonghe J, Bogaards M. et al. . Haloperidol prophylaxis for the elderly hip–surgery patients at risk for delirium: a randomized placebo–controlled study.  J Am Geriatr Soc. 2005;  53 1658-1666
• 45 Schrader S, Wellik K, Demaerschalk B. et al. . Adjunctive haloperidol prophylaxis reduces postoperative delirium severity and duration in at–risk elderly patients.  Neurologist. 2008;  14 134-37
• 46 Ancelin M, de Roquefeuil G, Bonnel B. et al. . Exposure to anaesthetic agents, cogntive functioning and depressive symptomatology in the eldery.  Br J Psychiatry. 2001;  178 360-366
• 47 Canet J, Raeder J, Rasmussen L. et al. . Cognitive dysfunction after minor surgery in the elderly.  Acta Anaesthesiol Scand. 2003;  47 1204-1210
• 48 Dijkstra J, Houx P, Jolles J.. Cognition after major surgery in the elderly: Test performance and complaints.  Br J Anaesth. 1999;  82 867-874
• 49 Moller J, Cluitmans P, Rasmussen L. et al. . Long–term postoperative cognitive dysfunction in the elderly: ISPOCD 1 study.  Lancet. 1998;  351 857-861
• 50 Billig N, Stockton P, Cohen–Mansfield J.. Cognitive and affective changes after cataract surgery in an elderly population.  Am J Geriatr Psychiatry. 1996;  2 29-38
• 51 Stockton P, Cohen–Mansfield J, Billig N.. Mental status change in older surgical patients: Cognition, depression, and other comorbidity.  Am J Geriatr Psychiatry. 2000;  8 40-46
• 52 Elam J, Marshall J, Graney M. et al. . Functional outcome one year following cataract surgery in elderly persons.  J Gerontol. 1988;  43 122-26
• 53 Goldstein M, Young B, Fogel B. et al. . Occurence and predictors of short–term mental and functional changes in older adults undergoing elective surgery under general anesthesia.  Am J Geriatr Psychiatry. 1998;  6 42-52
• 54 Gilberstadt H, Aberwald R, Crosbie S. et al. . Effect of surgery on psychological and social functioning in elderly patients.  Arch Intern Med. 1968;  122 109-115
• 55 Hall T, McGwin G, Owsley C.. Effect of cataract surgery on cognitive function in older adults.  J Am Geriatr Soc. 2005;  53 2140-2144
• 56 Abildstrom H, Rasmussen L, Rentowl P. et al. . Cognitive dysfunction 1–2 years after non–cardiac surgery in the elderly.  Acta Anaesthesiol Scand. 2000;  44 1246-1251
• 57 Folstein M, Folstein S, McHugh P.. "Mini Mental State" – A practical method for grading the cognitive state of patients for the clinician.  J Psychiatr Res. 1975;  12 189-198
• 58 Strauss E, Sherman E, Spreen O.. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary Oxford. 2006