Der demenzkranke Patient – Was ist beim anästhesiologischen Management zu beachten?

Zusammenfassung

Aus der Alterung der Gesellschaft erklärt sich, dass Patienten mit demenziellen Erkrankungen dem Anästhesisten immer häufiger begegnen. Die Patienten und Angehörigen sind darüber besorgt, dass Anästhesie eine bestehende Demenz aggraviert oder eine postoperative Demenz (POD) hervorrufen kann. Von einigen üblichen volatilen Hypnotika und auch von Propofol ist im Tierversuch nachgewiesen worden, dass sie die Konzentration der mit einer Demenz verknüpften Proteine Tau und Beta-Amyloid im Liquor erhöhen. Die perioperativen Komplikationen kognitive Dysfunktion und Delir dieses speziellen Kollektivs treten vergleichsweise häufiger auf als in der Normalbevölkerung. Es scheint aus anästhesiologischer Sicht wichtig, regelhaft die Erkrankung Demenz präoperativ zu erfassen, um Narkoseführung und Monitoring intra- und postoperativ darauf abstimmen zu können. Zu dem interagieren Antidementiva wie Azetylcholinesterasehemmer und andere neurotrope Medikamente mit den routinemäßige in gesetzten Anästhetika.

Generell ist bei Menschen mit Demenz die kognitive Beeinträchtigung von Konzentration, Erinnerung, Informationsverarbeitung, Sprachverständnis und soziale Anpassungsfähigkeit anzunehmen und im perioperativen Management zu berücksichtigen. Diese Übersicht soll den gegenwärtigen Stand der wissenschaftlichen Kenntnisse zum Thema zusammentragen und ihn zu Empfehlungen zum perioperativen Management dieser Patenten entwickeln.

Abstract

The aging society challenges anaesthesiologists with a growing number of patients with dementia. These and their relatives worry about an aggravation of an already existing dementia or even the postoperative evocation of one. Common volatile anaesthetics and propofol are suspected to increase dementia – associated protein tau and amyloid-betalevels in the brain. Perioperative complications such as cognitive dysfunction and delirium occur more frequently in dementia patients. For anaesthesiologists, it seems prudent toassess the grade of dementia in the elderly to adjust anaesthesia drug doses and monitoring intra- and postoperatively. Pharmacological interactions with antidementic andneuroleptic current medications affectanaesthetic and analgesic effects.In dementia, perioperative malfunction of cognition, memory, attention, information processing, communication and social interaction abilities is of profound influence on the perioperative management.

This review mentions actual knowledge about dementia forms and symptoms in brief. Recommendations for the anaesthesia care are given in more detail.

Kernaussagen

• Bei der Prämedikation sind insbesondere die Fremd- und Medikamentenanamnese, der Demenzschweregrad, der Betreuungsstatus und die den Pflegenden bekannten Schmerzäußerungshinweise zu erheben.

• Lebenshilfen wie Hörgeräte oder Gedächtnis- und Kommunikationshilfen sollten den Patienten nicht entzogen werden. Präoperative Blutzuckerentgleisungen und Bluttransfusionen erhöhen die Delirgefahr.

• Der perioperativen Abschirmung ist aufgrund der häufig vorhandenen Angst und der vergesellschafteten Depression ein hoher Stellwert einzuräumen.

• Anästhesiologische Verfahren, die eine sichere und effektive Analgesie versprechen (kontinuierliche Regionalanästhesietechniken), und Monitoringmethoden, die zur Reduktion der gesamten Dosis an neurotropen Medikamenten beitragen (Narkosetiefenmonitoring), sollten angewandt werden.

• Demenzkranke erfahren z.T. eine erhöhte Sensibilität für Anästhestika und Neuroleptika, die eine Reduktion auf ca. ein Drittel der üblichen Dosis bedingt. Andererseits kann eine Resistenz vorliegen (z. B. auf NSAID bei der hereditären DAT).

• Die Resistenz gegen Muskelrelaxanzien hängt von der Dauer der Antidementivatherapie ab. Succinylcholin kann verlängert wirken.

• Der Analgetikabedarf von Demenzkranken ist eher erhöht.

• Die Interaktionen der perioperativ notwendigen Medikamente mit den zur Demenz- und Depressionstherapie häuslich verordneten Medikamenten sollten ebenso berücksichtigt werden wie bekannte Organminderfunktionen, die zu einer veränderten Pharmakologie führen.

• Die postoperative Schmerztherapie soll anhand spezieller Algometrie beim Dementen laut S3-Leitlinie zur Anwendung kommen.

• Bei den demenzspezifischen perioperativen Komplikationen sind postoperatives kognitives Defizit, postoperative Demenz, Delir, zentrales anticholinerges Syndrom, Serotonin-Syndrom und malignes neuroleptisches Syndrom abzuwägen.

Schlüsselwörter:

Demenztypisierung - Prämedikation des Demenzkranken - Schmerztherapie bei demenziellen Erkrankungen - Narkoseführung beim Dementen - POCD - Delir - postoperative Demenz

Key words:

dementia type - preassessment of dementia patients - pain therapy in dementedpatients - anaesthesia management for dementia - POCD - delirium - postoperative dementia

• Literaturverzeichnis

• 1 Bickel H. Epidemiologie und Gesundheitsökonomie. In: Wallesch CW, Förstl H, Hrsg. Demenzen. 2. Aufl. Stuttgart: Thieme; 2012: 417-417
• 2 Hogan KJ. Hereditary vulnerabilities to post-operative cognitive dysfunction and dementia. ProgNeuropsychopharmacolBiol Psychiatry 2013; 47: 128-134
• 3 Kelleher RJ, Soiza RL. Evidence of endothelial dysfunction in the development of Alzheimer's disease: Is Alzheimer's a vascular disorder?. Am J CardiovascDis 2013; 3: 197-226
• 4 Sato N, Morishita R. Roles of vascular and metabolic components in cognitive dysfunction of Alzheimer disease: short- and long-term modification by non-genetic risk factors. Front Aging Neurosci 2013; 5: 64-64
• 5 Prins ND, Scheltens P. Treating Alzheimer's disease with monoclonal antibodies: current status and outlook for the future. Alzheimer's Res Ther 2013; 5: 56-56
• 6 Chen PL, Yang CW, Tseng YK et al. Risk of dementia after anaesthesia and surgery. Br J Psychiatry 2014; 204: 188-193
• 7 Chen CW, Lin CC, Chen KB et al. Increased risk of dementia in people with previous exposure to general anesthesia: A nationwide population-based case-control study. Alzheimer's Dement 2013;
• 8 Bekker A, Lee C, de Santi S et al. Does mild cognitive impairment increase the risk of developing postoperative cognitive dysfunction?. Am J Surg 2010; 199: 782-788
• 9 Breshears JD, Roland JL, Sharma M et al. Stable and dynamic cortical electrophysiology of induction and emergence with propofol anesthesia. ProcNatlAcadSci USA 2010; 107: 21170-21175
• 10 Bohnen NI, Warner MA, Kokmen E et al. Alzheimer's disease and cumulative exposure to anesthesia: a case-control study. J Am GeriatrSoc 1994; 42: 198-201
• 11 Gasparini M, Vanacore N, Schiaffini C et al. A case-control study on Alzheimer's disease and exposure to anesthesia. NeurolSci 2002; 23: 11-14
• 12 Knopman DS. Current treatment of mild cognitive impairment and Alzheimer's disease. CurrNeurolNeurosci Rep 2006; 6: 365-371
• 13 Bufill E, Bartes A, Moral A et al. Prevalence of cognitive deterioration in people over 80-years-old: COGMANLLEU study. Neurologia 2009; 24: 102-107
• 14 Lee TA, Wolozin B, Weiss KB et al. Assessment of the emergence of Alzheimer's disease following coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty. J Alzheimers Dis 2005; 7: 319-324
• 15 Seitz DP, Reimer CL, Siddiqui N. A review of epidemiological evidence for general anesthesia as a risk factor for Alzheimer's disease. ProgNeuropsychopharmacolBiol Psychiatry 2013; 47: 122-127
• 16 Tang JX, Baranov D, Hammond M et al. Human Alzheimer and inflammationbiomarkers after anesthesia and surgery. Anesthesiology 2011; 115: 727-732
• 17 Xie Z, Xu Z. General anestheticsand beta-amyloid protein. ProgNeuropsychopharmacolBiol Psychiatry 2013; 47: 140-146
• 18 Whittington RA, Bretteville A, Dickler MF et al. Anesthesia and tau pathology. ProgNeuropsychopharmacolBiol Psychiatry 2013; 47: 147-155
• 19 Dong Y, Zhang G, Zhang B et al. The common inhalational anesthetic sevofluraneinduces apoptosis and increases beta-amyloid protein levels. ArchNeurol 2009; 66: 620-631
• 20 Lu Y, Wu X, Dong Y et al. Anesthetic sevoflurane causes neurotoxicity differently inneonatal naive and Alzheimer disease transgenic mice. Anesthesiology 2010; 112: 1404-1416
• 21 Zhang Y, Dong Y, Wu X et al. The mitochondrial pathway of anesthetic isoflurane-inducedapoptosis. J BiolChem 2010; 285: 4025-4037
• 22 Zhang Y, Xu Z, Wang H et al. Anesthetics isoflurane and desflurane differently affectmitochondrial function, learning, and memory. AnnNeurol 2012; 71: 687-698
• 23 Palotás M, Palotás A, Bjelik A et al. Effect of general anesthetics on amyloidprecursor protein and mRNA levels in the rat brain. Neurochem Res 2005; 30: 1021-1026
• 24 Holtta E, Laakkonen ML, Laurila JV et al. The overlap of delirium withneuropsychiatric symptoms among patients with dementia. Am JGeriatr Psychiatry 2011; 19: 1034-1041
• 25 Lee HB, Mears SC, Rosenberg PB et al. Predisposing factors for postoperativedelirium after hip fracture repair in individuals with and without dementia. J Am GeriatrSoc 2011; 59: 2306-2313
• 26 Bilotta F, Doronzio A, Stazi E et al. Postoperative cognitive dysfunction: toward theAlzheimer's disease pathomechanism hypothesis. J Alzheimers Dis 2010; 22 (Suppl. 03) 81-89
• 27 Silverstein JH, Deiner SG. Perioperative delirium and its relationship to dementia. ProgNeuropsychopharmacolBiol Psychiatry 2013; 43: 108-115
• 28 Fong TG, Jones RN, Shi P et al. Delirium accelerates cognitive decline in Alzheimerdisease. Neurology 2009; 72: 1570-1575
• 29 Lundstrom M, Edlund A, Bucht G et al. Dementia after delirium in patients with femoralneck fractures. J Am GeriatrSoc 2003; 51: 1002-1006
• 30 Baranov D, Bickler PE, Crosby GJ et al. Consensus statement: First internationalworkshop on anesthetics and Alzheimer's disease. AnesthAnalg 2009; 108: 1627-1630
• 31 Adler G, Bektas M, Hoffmann P. The memory and attention test (MAT): an adaptive, computer-based performance test for early recognition and treatment evaluation in dementia. EurPsychiatry 2009; 24 (Suppl. 01)
• 32 Adler G, Bektas M, Feger M et al. Computer-based assessment of memory andattention: evaluation of the Memory and Attention Test (MAT). PsychiatrischePraxis 2012; 39: 79-83
• 33 Nicholson G, Pereira AC, Hall GM. Parkinson's disease and anaesthesia. BrJ Anaesth 2002; 89: 904-916
• 34 Ansaloni L, Catena F, Chattat R et al. Risk factors and incidence of postoperativedelirium in elderly patients after elective and emergency surgery. Br JSurg 2010; 97: 273-280
• 35 Meehan KM, Wang HE, David SR et al. Comparison of rapidly acting intramuscularolanzapine, lorazepam, and placebo: A double-blind, randomized study in acutelyagitated patients with dementia. Neuropsychopharmacology 2002; 26: 494-504
• 36 Battaglia J, Lindborg SR, Alaka K et al. Calming versus sedative effects ofintramuscular olanzapine in agitated patients. Am J EmergMed 2003; 21: 192-198
• 37 Pijnenburg YAL, Sampson EL, Harvey RJ et al. Vulnerability to neuroleptic side effectsin frontotemporal lobar degeneration. IntJGeriatrPsychiatry 2003; 18: 67-72
• 38 Margolis DJ, Knauss J, Bilker W et al. Medical conditions as risk factors for pressureulcers in an outpatient setting. Age Ageing 2003; 32: 259-264
• 39 Xiao H, Run X, Cao X et al. Temperature control can abolish anesthesia-induced tauhyperphosphorylation and partly reverse anesthesia-induced cognitive impairmentin old mice. Psychiatry ClinNeurosci 2013; 67: 493-500
• 40 Sieber FE, Zakriya KJ, Gottschalk A et al. Sedation depth during spinal anesthesiaand the development of postoperative delirium in elderly patients undergoing hipfracture repair. Mayo ClinProc 2010; 85: 18-26
• 41 Chan MTV, Cheng BCP, Lee TMC et al. BIS-guided anesthesia decreasespostoperative delirium and cognitive decline. JNeurosurgAnesth 2013; 25: 33-42
• 42 Renna M, Handy J, Shah A. Low baseline Bispectral Index of theelectroencephalogram in patients with dementia. AnesthAnalg 2003; 96: 1380-1385
• 43 Renna M, Venturi R. Bispectral index and anaesthesia in the elderly. MinervaAnestesiol 2000; 66: 398-402
• 44 Achterberg WP, Pieper MJ, van Dalen-Kok AH et al. Pain management in patientswith dementia. ClinIntervAging 2013; 8: 1471-1482
• 45 Bilotta F, Gelb AW, Stazi E et al. Pharmacological perioperative brain neuroprotection:a qualitative review of randomized clinical trials. Br J Anaesth 2013; 110: 113-120
• 46 Miyamoto E, Nakao S, Tomimoto H et al. Ketamine attenuates hypocapnia-inducedneuronal damage in the caudoputamen in a rat model of chronic cerebralhypoperfusion. Neurosc Letters 2004; 354: 26-29
• 47 Arain SR, Kern S, Ficke DJ et al. Variability of duration of action of neuromuscularblockingdrugs in elderly patients. ActaAnaesthesiol Scan 2005; 49: 312-315
• 48 Funder KS, Steinmetz J, Rasmussen LS. Anaesthesia for the patient with dementiaundergoing outpatient surgery. CurrOpinAnaesthesiol 2009; 22: 712-717
• 49 Di Nino G, Adversi M, Dekel BG et al. Peri-operative risk management in patients withAlzheimer's disease. J Alzheimers Dis 2010; 22 (Suppl. 03) 121-127
• 50 Beaussier M, El Ayoubi H, Schiffer E et al. Continuous preperitoneal infusion ofropivacaine provides effective analgesia and accelerates recovery after colorectalsurgery – A randomized, double-blind, placebo-controlled study. Anesthesiology 2007; 107: 461-468
• 51 Perrier V, Julliac B, Lelias A et al. Bloc iliofascial et troubles cognitifspostopératoires chez la personneâgée. AnnFrAnesthReanim 2010; 29: 283-288
• 52 Dalmas AF, Pougeoise M, Helou N et al. Anesthésiepourcésarienne et maladie de Creutzfeldt-Jakob. Ann FrAnesthReanim 2010; 29: 815-817
• 53 Estebe JP. Anesthésie et agents transmissibles non conventionnels (ou maladies à prions). Ann FrAnesthReanim 1997; 16: 955-963
• 54 Fodale V, Santamaria LB. Drugs of anesthesia, central nicotinic receptors and postoperativecognitive dysfunction. ActaAnaesthesiol Scan author reply 2003; 47
• 55 Hejmadi MV, Dajas-Bailador F, Barns SM et al. Neuroprotection by nicotine againsthypoxia-induced apoptosis in cortical cultures involves activation of multiplenicotinic acetylcholine receptor subtypes. Mol Cell Neurosci 2003; 24: 779-786
• 56 Schifilliti D, Santamaria LB, Rosa G et al. Cholinergic central system, Alzheimer'sdisease, and anesthetics liaison: a vicious circle?. J Alzheimers Dis 2010; 22 (Suppl. 03) 35-41
• 57 Sanchez Morillo J, Demartini Ferrari A, Roca de Togores Lopez A. Interaction ofdonepezil and muscular blockers in Alzheimer's disease. RevisEspAnestesiolReanim 2003; 50: 97-100
• 58 Ibebunjo C, Donati F, Fox GS et al. The effects of chronic tacrine therapy on dtubocurarineblockade in the soleus and tibialis muscles of the rat. AnesthAnalg 1997; 85: 431-436
• 59 Verborgh C. Anaesthesia in patients with dementia. CurrOpinAnaesthesiol 2004; 17: 277-283
• 60 Miyamoto E, Tomimoto H, Nakao Si S et al. Caudoputamen is damaged byhypocapnia during mechanical ventilation in a rat model of chronic cerebralhypoperfusion. Stroke 2001; 32: 2920-2925
• 61 Paris D, Humphrey J, Quadros A et al. Vasoactive effects of A beta in isolated humancerebrovessels and in a transgenic mouse model of Alzheimer's disease: role of inflammation. NeurolRes 2003; 25: 642-651
• 62 Overshott R, Karim S, Burns A. Cholinesterase inhibitors for delirium. CochraneDatabase SystReviews Cd 005317 2008; 1
• 63 Manfredi PL, Breuer B, Meier DE et al. Pain assessment in elderly patients withsevere dementia. J Pain Symptom Manag 2003; 25: 48-52
• 64 Pesonen A, Kauppila T, Tarkkila P et al. Evaluation of easily applicable painmeasurement tools for the assessment of pain in demented patients. ActaAnaesthesiol Scan 2009; 53: 657-664
• 65 Hadjistavropoulos T, LaChapelle DL, Hadjistavropoulos HD et al. Using facialexpressions to assess musculoskeletal pain in older persons. Eur JPain 2002; 6: 179-187
• 66 Mertens J, Stuber K, Wunderlich P et al. APP processing in human pluripotent stemcell-derived neurons is resistant to NSAID-based gamma-secretasemodulation. Stem Cell Rep 2013; 1: 491-498
• 67 Chen CC-H, Lin M-T, Tien Y-W et al. Modified Hospital Elder Life Program: Effects onabdominal surgery patients. J Am CollSurg 2011; 213: 245-252
• 68 Rudolph JL, Marcantonio ER. Review articles: postoperative delirium: acute changewith long-term implications. AnesthAnalg 2011; 112: 1202-1211
• 69 Hughes CG, Pandharipande PP. Review articles: the effects of perioperative andintensive care unit sedation on brain organ dysfunction. AnesthAnalg 2011; 112: 1212-1217
• 70 Fong HK, Sands LP, Leung JM. The role of postoperative analgesia in delirium andcognitive decline in elderly patients: A systematic review. AnesthAnalg 2006; 102: 1255-1266
• 71 Hirota T, Kishi T. Prophylactic antipsychotic use for postoperative delirium: asystematic review and meta-analysis. JClinPsychiatry 2013; 74: 1136-1144
• 72 Teslyar P, Stock VM, Wilk CM et al. Prophylaxis with antipsychotic medicationreduces the risk of post-operative delirium in elderly patients: a meta-analysis. Psychosomatics 2013; 54: 124-131
• 73 Lagger V, Imhof RM, Imhof L. Schmerzmanagement bei Patienten mit kognitiven Beeinträchtigungen: ein Forschungsanwendungsprojekt. Pflege 2008; 21: 149-156
• 74 Iadecola C. The pathobiology of vascular dementia. Neuron 2013; 80: 844-866
• 75 Boutajangout A, Wisniewski T. The Inate Immune System in Alzheimer's Disease. IntJCell Biol [Epub ahead of print] 2013;
• 76 Acquatella-Tran Van Ba I, Imberdis T, Perrier V et al. From prion diseases to prion-like propagation mechanisms of neurodegenerative diseases. Int JCell Biol [Epub ahead of print] 2013; 8
• 77 Morales R, Estrada LD, Diaz-Espinoza R et al. Molecular cross talk betweenmisfolded proteins in animal models of Alzheimer's and prion diseases. J Neurosci 2010; 30: 4528-4535
• 78 Eisele YS. From soluble aβ beta to progressive aβ aggregation: could prion-liketemplatedmisfolding play a role?. Brain Pathol 2013; 23: 333-341
• 79 Loy CT, Schofield PR, Turner AM et al. Genetics of dementia. Lancet 2014; 383: 828-840