Postoperative Cognitive Dysfunction In Elderly Patients After Urologic Part 2

Postoperative Cognitive Dysfunction In Elderly Patients After Urologic Part 2


The pathogenesis of postoperative cognitive dysfunction (POCD) was not completely clarified.7 However, it is reported that age, alcohol addiction, low intellectual capacity, low educational level, hypoxia, perioperative or postoperative hypotension, hypoxemia, surgery type, size and time can be effective in POCD formation.3,8

It has been claimed that mild depression and mild decrease in cognitive functions in elderly patients can increase with surgery and POCD can be detected with tests measuring cognitive functions.9 There are wide series regarding POCD and delirium development in elderly patients after major abdominal and orthopedical surgery procedures.3,10  POCD is not infrequent among elderly patients undergoing major surgery. In a study where healthy voluntaries and patients who were aged over 65 years and underwent major surgery were compared, it was detected that POCD frequency after 1 week was 27% in the group having undergone surgery and there was a significant difference as compared to the healthy group.9

Rasmussen et al. did not find any difference, particularly in long term, between the effects of general and regional anesthesia on POCD in a study they conducted on 438 elderly patients who would undergo major surgery.10 Therefore, the discussion emerged asserting that surgery or surgery stress could also affect POCD development together with or apart from anesthesia. POCD development risk in patients receiving general anesthesia was significantly higher in early period as compared to the control group. In addition to the aforementioned factors in POCD development, early POCD can also be related to decreasing metabolic rate and extending effects of residual volatile anesthetics in elderly patients. Therefore the anesthesia method and drugs to be chosen can affect early recovery and POCD development.11

Postoperative Cognitive Dysfunction In Elderly Patients After Urologic Part 2

In our study, we compared effects of BIA and TIVA on early recovery and cognitive functions in elderly patients undergoing elective urological surgery. The patients aged over 60 years who would undergo urological surgery with both endoscopic and open methods. Urological procedures comprise short and endoscopic attempts as well as intraabdominal major surgeries and the patient population is generally comprised of elderly patients. Therefore the anesthesia method to be chosen should enable rapid recovery and ambulation and affect postoperative cognitive functions at the minimum level.12 We used sevoflurane as inhalation anesthetic. As compared to low blood-gas partition coefficient and other traditional anesthetics, sevoflurane provides a more rapid and quality recovery process.13,14 No other inhalation anesthetic as N2O was used in either of the groups in order to evaluate the pure effect in both groups; and it was aimed to evaluate only the effect of sevuflurane and propofol. Although N2O was generally used in studies, the number of the studies where it was not used was not low, either.15 In both groups, remifentanil which rapidly metabolized regardless of the dose amount for preoperative analgesia purposes. Generally propofol and remifentanil combination is used for TIVA.16 This combination is promising due to the short effects of the both drugs it comprises. On the other hand, blood concentrations of propofol and remifentanil are not affected by each other.17 It has been claimed that remifentanil is an opioid which is appropriate for continuous IV infusion due to its pharmacodynamics and pharmacokinetic characteristics and prevents hemodynamic response to tracheal intubation and skin cuts. The suggested remifentanil dose is 1µ for induction and 0.25-1.0µ for maintenance.18 We used similar doses in our studies, as well.

In our study, TIVA and BIA were compared in terms of postoperative hemodynamic, recovery and POCD parameters. In the study conducted by Larsen et al., desflurane/fentanyl/N2O and sevoflurane/fentanyl/N2O anesthesia were compared to TIVA applied with propofol. They reported that the most important advantage of TIVA is to provide a more rapid recovery as compared to the other groups. The authors stated that the reason for recovery delay in the inhalation anesthesia group is the residual effect of fentanyl.11 In the study where Kubitz et al. compared TIVA and BIA in cataract surgery in elderly patients, they reported that the recovery was more rapid in TIVA group.19 Long-effect opioid (fentanyl) was also used in the BIA group of this study. There are also studies which assert that there are no difference between TIVA and BIA in terms of recovery parameters.11 We used remifentanil in both groups. When the recovery parameters of groups were compared, eye opening time was significantly longer in the group receiving TIVA. This difference may have resulted by the delayed metabolization of propofol in elderly patients. In a compilation where Gupta et al. reviewed the recovery parameters after ambulatory surgery (11 studies and 821 patients), they also compared propofol and sevoflurane anesthesia and detected that there was no difference between eye opening times, the sevoflurane group could more rapidly perform the instructions, discharge period of the propofol group was approximately 10 minutes shorter, postoperative nausea/vomiting and antiemetic use were higher in the sevoflurane group.15 With cognitive dysfunction, erectile dysfunction may occur, which is treated with Viagra.

It was demonstrated that after exposition to anesthetic substances, a deterioration lasting 10-12 minutes occur in psychomotor and cognitive functions, this deterioration may last for 1-2 days with sensible tests and even continue for 3 months.3,20 Chung et al. reported that short-effect anesthetics caused deterioration in cognitive functions of elderly patients only in the 1st postoperative day.21  Abildstrom et al. reported that postoperative cognitive functions were recovered in elderly patients and it could be permanent in 1% of them.22 In a study where Chen et al. searched for the effects of sevoflurane and desflurane anesthesia in cognitive functions of elderly patients, they demonstrated that while there was a decrease in cognitive functions of both groups in the 1st postoperative hour, there was no difference in the cognitive functions in 2nd, 3rd, 6th and 24th hours as compared to the baseline level.23 In our study, cognitive functions in postoperative 1st, 2nd and 24th hours were measured and there were no difference between Group I and Group T. The obtained postoperative MMSET values were in compliance with the literature.20,24 In a study where Özünlü et al. examined the effect of anesthesia method in daily gynaecologic laparoscopy on nausea, vomiting and cognitive functions, they compared TIVA and BIA groups and did not find any difference in terms of cognitive functions.25 In a compilation where Newman et al. evaluated postoperative cognitive functions in patients undergoing noncardiac surgery, similarly there were no difference between inhalation and intravenous anesthesia methods in terms of cognitive functions. However, evaluation time was set as 4-8 weeks in this study. The same study reported that POCD can develop in early period (within weeks) in a significant majority of patients undergoing noncardiac surgery and the risk increases with age.26  On the contrary, in our study when the groups were evaluated within themselves, there was no difference between preoperative MMSET values and postoperative MMSET values. MMSET values demonstrated an increase in the later hours of postoperative period. This increase was selected as significant between MMSET1 and MMSET2; and MMSET24 in Group T. This case may have resulted from the fact that the cases memorized the answers after being exposed to the same questions for the 4th time.

In particularly elderly patients undergoing surgery, psychomotor and cognitive decreases occurring in postoperative period affect life qualities of cases and lead to social and economic results. Even the relation of long-term POCD to mortality was searched but not proven clearly. However, its effect increasing the mortality in “young” ages (60-75) was demonstrated to be higher as compared to “elderly” patients. Since POCD is frequently associated with cardiac surgery, information on the conditions after non-cardiac surgery are relatively less. Therefore, it is a subject worth to study and clarify.27

It should be understood that POCD is a problem more frequently encountered in early postoperative period and even in the first hours but is permanent in a limited number of patients. In our study where we compared BIA and TIVA in patients aged over 60 years and undergoing urological surgery, there was no difference between groups in terms of postoperative cognitive functions and no difference within groups in terms of pre/postoperative cognitive functions.

 Group I (n=20)Group T (n=20)p
Age (year)70,95±6,68 (60-80)69,15±5,76 (60-80)0.35
Gender (M/F)19 / 118 / 2


BMI (kg/m2)25,30±4,0626,66±3,300.18
Educational Status (uneducated/educated)6/14




MMSET0 values23,35±3,9523,2±3,440.77
ASA physical condition (I/II/III)7/13/08/11/10.53
Types of surgery (endoscopic/open)16/415/50.71
Anesthesia duration (min)79,4±35,7773,05±28,390.58
Surgery duration (min)70,6±34,6163,9±27,790.51


Table 1: There were no significant differences between the groups in terms of age, sex, BMI, educational status, MMSET0 values, ASA physical condition, surgery types (endoscopic/open), anesthesia times and surgery times. (BMI: Body Mass Index, MMSET0: Mini Mental State Examination Test, MAP0: Median Arterial Pressure, HR0: Heart Rate baseline, ASA: American Society of Anesthesiology

 Group I (n=20)Group T (n=20)p
Beginning Time of Spontaneous Ventilation232,05±107,52283,60±132,110,19
Extubation Time384,95±153,04485,20±200,780,12
Spontaneous Eye Opening Time265,90±139,16384,20±132,560,009*
The Time When Of The Patient Could Tell His Name470,25±155,0530,85±191,490,29


LANGUAGE (9 points in total)

  1. a) What are these objects? (watch, pencil) 2 points (wait for 20 seconds): ( )
  2. b) Please carefully listen to the sentence I will tell and repeat after me. “If and but I do not want ” (wait for 10 seconds) 1 points: ( )
  3. c) Now I will want you to do something, please carefully listen to me and do what I say. “Take the paper on the table with your right/left hand, fold it into two and put it to the floor” 3 points in total, time is 30 seconds, 1 points for each action: ( )
  4. d) Now I will give you a sentence. Please read it and do what it says. (1 point)

“CLOSE YOUR EYES” (on the back of the page): ( )

  1. e) Please write the first meaningful sentence that comes up to your mind on the paper I give you (1 point): ( )
  2. f) Please draw the shape I will show you. (on the back of the page) (1 point)

SAVING MEMORY (3 points in total)

Please carefully listen to the three words that I will tell you and repeat after me

(Table, Flag, Dress) (wait for 20 seconds) Each correct word is 1 point: ( )

ATTENTION and CALCULATION (5 points in total)

Count the day of week backwards from sunday.

Five correct day  is 1 point: ( )

REMEMBERING (3 points in total)

Do you remember the words you repeated after me? Tell me those you remember.

(Table, Flag, Dress): ( )

LANGUAGE (9 points in total)

  1. a) What are these objects? (watch, pencil) 2 points (wait for 20 seconds): ( )
  2. b) Please carefully listen to the sentence I will tell and repeat after me. “If and but I do not want ” (wait for 10 seconds) 1 points: ( )
  3. c) Now I will want you to do something, please carefully listen to me and do what I say. “Take the paper on the table with your right/left hand, fold it into two and put it to the floor” 3 points in total, time is 30 seconds, 1 points for each action: ( )
  4. d) Now I will give you a sentence. Please read it and do what it says. (1 point)

“CLOSE YOUR EYES” (on the back of the page): ( )

  1. e) Please say anything about your home (a meaningful sentence, I give you (1 point): ( )
  2. f) Please draw the shape I will show you. (on the back of the page) (1 point)

Figure 2: Mini Mental State Examination Test for the Untutored (MMSETU)

Figure 3: Postoperative MMSET values                                                                                  (MMSET1: MMSET value in 1.hour, MMSET2: MMSET value in 2.hour,               MMSET24: MMSET value in 24.hour)


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  2. Krenk L, Rasmussen LS. Postoperative delirium and postoperative cognitive dysfunction in the elderly – what are the differences? Minerva Anestesiol. 2011; 77(7): 742-9
  3. Monk TG, Weldon BC, Garvan CW, et al. Predictors of cognitive dysfunction after major noncardiac surgery. Anesthesiology 2008; 108: 18-30
  4. Hanning CD. Postoperative cognitive dysfunction. Br J Anesth 2005; 95(1): 82-7
  5. Giordani B, Boivin MJ, Hall AI. The utility and generality of Mini Mental Examination Scores in Alzheimer’s disease. Neurology 1990; 40: 1894-96
  6. Filenbaum GC, Heyman A, Wilkinson WE, Haynes CE. Comparison of two screening tests in Alzheimer’s disease: The correlation and reliability of the MMSE and Modified Blessed Test. Arch Neurology 1987; 44: 924-27
  7. Rasmussen LS, Johnson T, Kuipers HM, et al. Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients. Acta Anaesth Scand 2003; 47: 260-6
  8. Rudolph JL, Schreiber KA, Culley DJ, et al. Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review. Acta Anaesthesiol Scand. 2010; 54(6): 663-77


9. Kudoh A, Takase H, Takahira Y, Takazawa T. Postoperative confusion increases in elderly long-term benzodiazepine users. Anesth Analg. 2004; 99(6): 1674-8

  1. Rasmussen LS, O’Brien JT, Silverstein JH, et al. ISPOCD 2 Investigators: Is perioperative cortisol secretion related to post-operative cognitive dysfunction? Acta Anaesthesiol Scand 2005; 49: 1225-31
  2. Bilotta F, Doronzio A, Stazi E, et al. Early postoperative cognitive dysfunction and postoperative delirium after anaesthesia with various hypnotics: study protocol for a randomised controlled trial–the PINOCCHIO trial. Trials. 2011; 12: 170
  3. Rortgen D, Kloos J, Fries M, et al. Comparison of early cognitive function and recovery after desflurane or sevoflurane anaesthesia in the elderly: a double-blinded randomized controlled trial. Br J Anaesth. 2010; 104(2): 167-74
  4. . Heavner JE, Kaye AD, Lin BK, King T. Recovery of elderly patients from two or more hours of desflurane or sevoflurane anaesthesia. Br J Anaesth. 2003; 91(4): 502-6
  5. Cremer J, Stoppe C, Fahlenkamp AV, et al. Early cognitive function, recovery and well-being after sevoflurane and xenon anaesthesia in the elderly: a double-blinded randomized controlled trial. Med Gas Res. 2011; 1(1): 9
  6. Pavlin DJ, Arends RH, Gunn HC, et al. Optimal propofol-alfentanil combinations for supplementing nitrous oxide for outpatient surgery. Anesthesiology. 1999; 91(1): 97-108
  7. Mertens MJ, Engbers FHM, Burm AGL, Vuyk J. Predictive performance of computer-controlled infusion of remifentanil during propofol/remifentanil anaesthesia. Br J Anesth 2003; 90(2): 132-41
  8. Ornek D, Metin S, Deren S, et al. The influence of various anesthesia techniques on postoperative recovery and discharge criteria among geriatric patients. Clinics (Sao Paulo). 2010; 65(10): 941-6
  9. Philip BK, Scuderi PE, Chung F, et al. Remifentanil compared with alfentanil for ambulatory surgery using total intravenous anesthesia. The Remifentanil/Alfentanil Outpatient TIVA Group. Anesth Analg. 1997; 84(3): 515-21
  10. Kubitz J, Epple J, Bach A, et al. Psychomotor recovery in very old patients after total intravenous or balanced anaesthesia for cataract surgery. Br J Anaesth 2001; 86(2): 203-8
  11. Evered L, Scott DA, Silbert B, Maruff P. Postoperative cognitive dysfunction is independent of type of surgery and anesthetic. Anesth Analg. 2011; 112(5): 1179-85
  12. Chung F, Seyone C, Dyck B, et al. Age-related cognitive recovery after general anesthesia. Anesth Analg 1990; 71: 217-24
  13. Abildstrom H, Rasmussen LS, Rentowl P, et al. Cognitive dysfunction 1-2 years after non-cardiac surgery in the elderly. Acta Anaesthesiol Scand 2000; 44: 1246-51
  14. Chen X, Zhao M, White P. The recovery of cognitive function after general anesthesia in elderly patients: A comparison of desflurane and sevoflurane. Anesth Analg 2001; 93: 1489-94
  15. Mortero RF, Clark LD, Tolan MM, Metz RJ, Tsueda K, Sheppard RA. The effects of small-dose ketamine on propofol sedation: respiration, postoperative mood, perception, cognition, and pain. Anesth Analg. 2001; 92(6): 1465-9
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By Padraic D. McCahill, M.D.On: May 03, 2019 at 15:08:52