Advertisement

An Update on Postoperative Cognitive Dysfunction

      Postoperative cognitive dysfunction or decline (POCD) is increasingly recognized as a common phenomenon after major surgery [
      • Williams-Russo P.
      • Sharrock N.
      • Mattis S.
      • et al.
      Cognitive effects after epidural vs general anesthesia in older adults.
      ,
      • Moller J.
      • Cluitmans P.
      • Rasmussen L.
      • et al.
      ISPOCD investigators: long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study.
      ,
      • Johnson T.
      • Monk T.
      • Rasmussen L.S.
      • et al.
      Postoperative cognitive dysfunction in middle-aged patients.
      ,
      • Rasmussen L.S.
      • Johnson T.
      • Kuipers H.M.
      • et al.
      Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients.
      ]. Because older age is a strong preoperative risk factor of POCD [
      • Moller J.
      • Cluitmans P.
      • Rasmussen L.
      • et al.
      ISPOCD investigators: long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study.
      ,
      • Monk T.G.
      • Weldon B.C.
      • Garvan C.W.
      • et al.
      Predictors of cognitive dysfunction after major noncardiac surgery.
      ], the incidence of POCD is expected to increase as the population of older surgical patients grows. Improving the measurement of POCD and identifying its etiology is clinically important, as recent studies have associated POCD with impairments in daily functioning [
      • Phillips-Bute B.
      • Mathew J.P.
      • Blumenthal J.A.
      • et al.
      Association of neurocognitive function and quality of life 1 year after coronary artery bypass graft (CABG) surgery.
      ], premature departure from the labor market [
      • Steinmetz J.
      • Christensen K.B.
      • Lund T.
      • et al.
      Long-term consequences of postoperative cognitive dysfunction.
      ], and dependency on government economic assistance after hospital discharge [
      • Steinmetz J.
      • Christensen K.B.
      • Lund T.
      • et al.
      Long-term consequences of postoperative cognitive dysfunction.
      ].
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Advances in Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Williams-Russo P.
        • Sharrock N.
        • Mattis S.
        • et al.
        Cognitive effects after epidural vs general anesthesia in older adults.
        JAMA. 1995; 274: 44-50
        • Moller J.
        • Cluitmans P.
        • Rasmussen L.
        • et al.
        ISPOCD investigators: long-term postoperative cognitive dysfunction in the elderly: ISPOCD1 study.
        Lancet. 1998; 351: 857-861
        • Johnson T.
        • Monk T.
        • Rasmussen L.S.
        • et al.
        Postoperative cognitive dysfunction in middle-aged patients.
        Anesthesiology. 2002; 96: 1351-1357
        • Rasmussen L.S.
        • Johnson T.
        • Kuipers H.M.
        • et al.
        Does anaesthesia cause postoperative cognitive dysfunction? A randomised study of regional versus general anaesthesia in 438 elderly patients.
        Acta Anaesthesiol Scand. 2003; 47: 260-266
        • Monk T.G.
        • Weldon B.C.
        • Garvan C.W.
        • et al.
        Predictors of cognitive dysfunction after major noncardiac surgery.
        Anesthesiology. 2008; 108: 18-30
        • Phillips-Bute B.
        • Mathew J.P.
        • Blumenthal J.A.
        • et al.
        Association of neurocognitive function and quality of life 1 year after coronary artery bypass graft (CABG) surgery.
        Psychosom Med. 2006; 68: 369-375
        • Steinmetz J.
        • Christensen K.B.
        • Lund T.
        • et al.
        Long-term consequences of postoperative cognitive dysfunction.
        Anesthesiology. 2009; 110: 548-555
      1. American Psychiatric Association. American Psychiatric Association, Task Force on DSM-IV: diagnostic and statistical manual of mental disorders: DSM-IV-TR, 4th edition. Washington, DC, American Psychiatric Association, 2000.

        • Murkin J.
        • Newman S.
        • Stump D.
        • et al.
        Statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery.
        Ann Thorac Surg. 1995; 59: 1289-1295
        • Lipowski Z.
        Delirium (acute confusional states).
        JAMA. 1987; 258: 1789-1792
        • Inouye S.
        • vanDyck C.
        • Alessi C.
        • et al.
        Clarifying confusion: the confusion assessment method.
        Ann Intern Med. 1990; 113: 941-948
        • Blumenthal J.
        • Mahanna E.
        • Madden D.
        • et al.
        Methodological issues in the assessment of neuropsychologic function after cardiac surgery.
        Ann Thorac Surg. 1995; 59: 1345-1350
        • Makensen G.
        • Gelb A.
        Postoperative cognitive deficits: more questions than answers.
        Eur J Anaesthesiol. 2004; 21: 85-88
        • Hanning C.D.
        Postoperative cognitive dysfunction.
        Br J Anaesth. 2005; 95: 82-87
        • Wu C.
        • Hsu W.
        • Richman J.
        • et al.
        Postoperative cognitive function as an outcome of regional anesthesia and analgesia.
        Reg Anesth Pain Med. 2004; 29: 257-268
        • Rudolph J.
        • Schreiber K.
        • Culley D.
        • et al.
        Measurement of post-operative cognitive dysfunction after cardiac surgery: a systematic review.
        Acta Anaesthesiol Scand. 2010; 54: 663-677
        • Lewis M.
        • Maruff P.
        • Silbert B.
        Statistical and conceptual issues in defining post-operative cognitive dysfunction.
        Neurosci Biobehav Rev. 2004; 28: 433-440
        • Bekker A.
        • Weeks E.
        Cognitive function after anaesthesia in the elderly.
        Best Pract Res Clin Anaesthesiol. 2003; 17: 259-273
        • Deiner S.
        • Silverstein J.H.
        Postoperative delirium and cognitive dysfunction.
        Br J Anaesth. 2009; 103: i41-i46
        • Newman S.
        • Stygall J.
        • Hirani S.
        • et al.
        Postoperative cognitive dysfunction after noncardiac surgery.
        Anesthesiology. 2007; 106: 572-590
        • Symes E.
        • Maruff P.
        • Ajani A.
        • et al.
        Issues associated with the identification of cognitive change following coronary artery bypass grafting.
        Aust N Z J Psychiatry. 2000; 34: 770-784
        • Rasmussen L.
        • Larsen K.
        • Houx P.
        • et al.
        The assessment of postoperative cognitive function.
        Acta Anaesthesiol Scand. 2001; 45: 275-289
        • Funder K.
        • Steinmetz J.
        • Rasmussen L.
        Methodological issues of postoperative cognitive dysfunction research.
        Semin Cardiothorac Vasc Anesth. 2010; 14: 119-122
        • Sands L.
        • Katz I.
        • Doyle S.
        Detecting subclinical change in cognitive functioning in older adults. Part I: Explication of the method.
        Am J Geriatr Psychiatry. 1993; 1: 1-13
        • Borkowski J.
        • Benton A.
        • Spreen O.
        Word fluency and brain damage.
        Neuropsychologia. 1967; 5: 135-140
        • Sauer A.M.
        • Kalkman C.
        • van Dijk D.
        Postoperative cognitive decline.
        J Anesth. 2009; 23: 256-259
        • Rafnsson S.B.
        • Deary I.J.
        • Smith F.B.
        • et al.
        Cardiovascular diseases and decline in cognitive function in an elderly community population: the Edinburgh Artery Study.
        Psychosom Med. 2007; 69: 425-434
        • Sands L.P.
        • Phinney A.
        • Katz I.R.
        Monitoring Alzheimer’s patients for acute changes in cognitive functioning.
        Am J Geriatr Psychiatry. 2000; 8: 47-56
        • Sands L.
        • Katz I.
        • Doyle S.
        Detecting subclinical change in cognitive functioning in older adults: part 2 initial validation of the method.
        Am J Geriatr Psychiatry. 1993; 1: 275-287
        • Keizer A.M.
        • Hijman R.
        • Kalkman C.J.
        • et al.
        The incidence of cognitive decline after (not) undergoing coronary artery bypass grafting: the impact of a controlled definition.
        Acta Anaesthesiol Scand. 2005; 49: 1232-1235
        • Silbert B.S.
        • Maruff P.
        • Evered L.A.
        • et al.
        Detection of cognitive decline after coronary surgery: a comparison of computerized and conventional tests.
        Br J Anaesth. 2004; 92: 814-820
        • Duggleby W.
        • Lander J.
        Cognitive status and postoperative pain: older adults.
        J Pain Symptom Manage. 1994; 9: 19-27
        • Heyer E.
        • Sharma R.
        • Winfree C.
        • et al.
        Severe pain confounds neuropsychological test performance.
        J Clin Exp Neuropsychol. 2000; 22: 633-639
        • Wang Y.
        • Sands L.
        • Vaurio L.
        • et al.
        The effects of postoperative pain and its management on postoperative cognitive dysfunction.
        Am J Geriatr Psychiatry. 2007; 15: 50-59
        • Ersek M.
        • Cherrier M.M.
        • Overman S.S.
        • et al.
        The cognitive effects of opioids.
        Pain Manag Nurs. 2004; 5: 75-93
        • Rasmussen L.
        • Stygall J.
        • Newman S.P.
        Cognitive dysfunction and other long-term complications of surgery and anesthesia.
        in: Miller R.D. Miller’s anesthesia. 7th edition. Churchill Livingstone/Elsevier, Philadelphia2009: 2v (xxii, 3084, I–89)
        • National Center for Health Statistics (U.S.)
        Health, United States, 2009: With Special Feature on Medical Technology.
        Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, Hyattsville (MD)2010
        • Fleischmann K.E.
        • Goldman L.
        • Young B.
        • et al.
        Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay.
        Am J Med. 2003; 115: 515-520
        • Rohan D.
        • Buggy D.J.
        • Crowley S.
        • et al.
        Increased incidence of postoperative cognitive dysfunction 24 hr after minor surgery in the elderly.
        Can J Anaesth. 2005; 52: 137-142
        • Rudolph J.L.
        • Marcantonio E.R.
        • Culley D.J.
        • et al.
        Delirium is associated with early postoperative cognitive dysfunction.
        Anaesthesia. 2008; 63: 941-947
        • Borowicz L.M.
        • Goldsborough M.A.
        • Selnes O.A.
        • et al.
        Neuropsychologic change after cardiac surgery: a critical review.
        J Cardiothorac Vasc Anesth. 1996; 10 ([quiz:111–2]): 105-111
        • Lowery D.P.
        • Wesnes K.
        • Brewster N.
        • et al.
        Subtle deficits of attention after surgery: quantifying indicators of sub syndrome delirium.
        Int J Geriatr Psychiatry. 2010; 25: 945-952
        • McDonagh D.L.
        • Mathew J.P.
        • White W.D.
        • et al.
        Cognitive function after major noncardiac surgery, apolipoprotein E4 genotype, and biomarkers of brain injury.
        Anesthesiology. 2010; 112: 852-859
        • Yaffe K.
        • Cauley J.
        • Sands L.
        • et al.
        Apolipoprotein E phenotype and cognitive decline in a prospective study of elderly community women.
        Arch Neurol. 1997; 54: 1110-1114
        • Slooter A.
        • Tang M.-X.
        • van Duign C.
        • et al.
        Apolipoprotein E e4 and the risk of dementia with stroke. A population-based investigation.
        JAMA. 1997; 277: 818-821
        • Henderson A.
        • Easteal S.
        • Jorm A.
        • et al.
        Apolipoprotein E allele e4, dementia, and cognitive decline in a population sample.
        Lancet. 1995; 346: 1387-1390
        • Maestre G.
        • Ottman R.
        • Stern Y.
        • et al.
        Apolipoprotein E and Alzheimer’s disease: ethnic variation in genotypic risks.
        Ann Neurol. 1995; 37: 254-259
        • Bird T.D.
        Genetic factors in Alzheimer’s disease.
        N Engl J Med. 2005; 352: 862-864
        • Dik M.
        • Jonker C.
        • Bouter L.
        • et al.
        APOE-e4 is associated with memory decline in cognitively impaired elderly.
        Neurology. 2000; 54: 1429-1497
        • Lahoz C.
        • Schaefer E.
        • Cupples L.
        • et al.
        Apolipoprotein E genotype and cardiovascular disease in the Framingham Heart Study.
        Atherosclerosis. 2001; 154: 529-537
        • Davignon J.
        • Gregg R.
        • Sing C.
        Apolipoprotein E polymorphism and atherosclerosis.
        Arteriosclerosis. 1988; 8: 1-21
        • Stengard J.
        • Zebra K.
        • Pekkanen J.
        • et al.
        Apolipoprotein E polymorphism predicts death from coronary heart disease in a longitudinal study of elderly Finnish men.
        Circulation. 1995; 91: 265-269
        • Mahley R.
        • Rall S.
        Type III hyperlipoproteinemia (dysbetalipoproteinemia): the role of apolipoprotein E in normal and abnormal lipoprotein metabolism.
        in: Scriver C. Beaudet A. Sly W. The metabolic and molecular bases of inherited disease. McGraw-Hill, New York2001: 2835-2862
        • Poirier J.
        • Hess M.
        • May P.
        • et al.
        Astrocytic apolipoprotein E mRNA and GFAP mRNA in hippocampus after entorhinal cortex lesioning.
        Brain Res Mol Brain Res. 1991; 11: 97-106
        • Boyle J.
        • Zoellner C.
        • Anderson L.
        A role for apolipoprotein E, apolipoprotein A-1, and low density lipoprotein receptors in cholesterol transport during regeneration and remyelination of rat sciatic nerve.
        J Clin Invest. 1989; 83: 1015-1031
        • LeBlanc A.
        • Poduslo J.
        Regulation of apolipoprotein E gene expression after injury of the rat sciatic nerve.
        J Neurosci Res. 1990; 25: 162-171
        • Mahley R.
        Apolipoprotein E: cholesterol transport protein with expanding role in cell biology.
        Science. 1988; 1988: 622-630
        • Tardiff B.E.
        • Newman M.F.
        • Saunders A.M.
        • et al.
        Preliminary report of a genetic basis for cognitive decline after cardiac operations. The Neurologic Outcome Research Group of the Duke Heart Center.
        Ann Thorac Surg. 1997; 64: 715-720
        • Heyer E.J.
        • Wilson D.A.
        • Sahlein D.H.
        • et al.
        APOE-epsilon4 predisposes to cognitive dysfunction following uncomplicated carotid endarterectomy.
        Neurology. 2005; 65: 1759-1763
        • Lelis R.G.
        • Krieger J.E.
        • Pereira A.C.
        • et al.
        Apolipoprotein E4 genotype increases the risk of postoperative cognitive dysfunction in patients undergoing coronary artery bypass graft surgery.
        J Cardiovasc Surg (Torino). 2006; 47: 451-456
        • Abildstrom H.
        • Christiansen M.
        • Siersma V.D.
        • et al.
        Apolipoprotein E genotype and cognitive dysfunction after noncardiac surgery.
        Anesthesiology. 2004; 101: 855-861
        • Leung J.
        • Sands L.
        • Wang Y.
        • et al.
        Apolipoprotein E e4 allele increases the risk of early postoperative delirium in older patients undergoing noncardiac surgery.
        Anesthesiology. 2007; 107: 406-411
        • Ely E.W.
        • Girard T.D.
        • Shintani A.K.
        • et al.
        Apolipoprotein E4 polymorphism as a genetic predisposition to delirium in critically ill patients.
        Crit Care Med. 2007; 35: 112-117
        • Parihar M.S.
        • Hemnani T.
        Alzheimer’s disease pathogenesis and therapeutic interventions.
        J Clin Neurosci. 2004; 11: 456-467
        • Tsuang D.W.
        • Bird T.D.
        Genetics of dementia.
        Med Clin North Am. 2002; 86: 591-614
        • Moretti E.W.
        • Morris R.W.
        • Podgoreanu M.
        • et al.
        APOE polymorphism is associated with risk of severe sepsis in surgical patients.
        Crit Care Med. 2005; 33: 2521-2526
        • Newman M.F.
        • Mathew J.P.
        • Grocott H.P.
        • et al.
        Central nervous system injury associated with cardiac surgery.
        Lancet. 2006; 368: 694-703
        • Selnes O.A.
        • Goldsborough M.A.
        • Borowicz L.M.
        • et al.
        Neurobehavioural sequelae of cardiopulmonary bypass.
        Lancet. 1999; 353: 1601-1606
        • Pugsley W.
        • Klinger L.
        • Paschalis C.
        • et al.
        The impact of microemboli during cardiopulmonary bypass on neuropsychological functioning.
        Stroke. 1994; 25: 1393-1399
        • Mathew J.P.
        • Shernan S.K.
        • White W.D.
        • et al.
        Preliminary report of the effects of complement suppression with pexelizumab on neurocognitive decline after coronary artery bypass graft surgery.
        Stroke. 2004; 35: 2335-2339
        • Jensen J.
        • Hedin L.
        • Widell C.
        • et al.
        Characteristics of heart failure in the elderly—a hospital cohort registry-based study.
        Int J Cardiol. 2008; 125: 191-196
        • Liu Y.H.
        • Wang D.X.
        • Li L.H.
        • et al.
        The effects of cardiopulmonary bypass on the number of cerebral microemboli and the incidence of cognitive dysfunction after coronary artery bypass graft surgery.
        Anesth Analg. 2009; 109: 1013-1022
        • Culley D.J.
        • Xie Z.
        • Crosby G.
        General anesthetic-induced neurotoxicity: an emerging problem for the young and old?.
        Curr Opin Anaesthesiol. 2007; 20: 408-413
        • Hole A.
        • Terjesen T.
        • Brevik H.
        Epidural versus general anaesthesia for total hip arthroplasty in elderly patients.
        Acta Anaesthesiol Scand. 1980; 24: 279-287
        • Berggren D.
        • Gustafson Y.
        • Eriksson B.
        • et al.
        Postoperative confusion after anesthesia in elderly patients with femoral neck fractures.
        Anesth Analg. 1987; 66: 497-504
        • O’Hara D.
        • Duff A.
        • Berlin J.
        • et al.
        The effect of anesthetic technique on postoperative outcomes in hip fracture repair.
        Anesthesiology. 2000; 92: 947-957
        • Williams-Russo P.
        • Sharrock N.
        • Mattis S.
        • et al.
        Randomized trial of hypotensive epidural anesthesia in older adults.
        Anesthesiology. 1999; 91: 926-935
        • Cibelli M.
        • Fidalgo A.
        • Terrando N.
        • et al.
        Role of interleukin-1beta in postoperative cognitive dysfunction.
        Ann Neurol. 2010; 68: 360-368
        • Kobbe P.
        • Vodovotz Y.
        • Kaczorowski D.J.
        • et al.
        Patterns of cytokine release and evolution of remote organ dysfunction after bilateral femur fracture.
        Shock. 2008; 30: 43-47
        • Wang J.J.
        Group reminiscence therapy for cognitive and affective function of demented elderly in Taiwan.
        Int J Geriatr Psychiatry. 2007; 22: 1235-1240
        • Rosczyk H.A.
        • Sparkman N.L.
        • Johnson R.W.
        Neuroinflammation and cognitive function in aged mice following minor surgery.
        Exp Gerontol. 2008; 43: 840-846
        • Terrando N.
        • Rei Fidalgo A.
        • Vizcaychipi M.P.
        • et al.
        The impact of IL-1 modulation on the development of lipopolysaccharide-induced cognitive dysfunction.
        Crit Care. 2010; 14: R88
        • Stern Y.
        What is cognitive reserve? Theory and research application of the reserve concept.
        J Int Neuropsychol Soc. 2002; 8: 448-460
        • Evans D.A.
        • Beckett L.A.
        • Field T.S.
        • et al.
        Apolipoprotein E epsilon4 and incidence of Alzheimer disease in a community population of older persons.
        JAMA. 1997; 277: 822-824
        • Zhang M.
        Zhonghua Yi Xue Za Zhi. 1990; 70 (30 [in Chinese]): 424-428
        • Letenneur L.
        • Commenges D.
        • Dartigues J.F.
        • et al.
        Incidence of dementia and Alzheimer’s disease in elderly community residents of south-western France.
        Int J Epidemiol. 1994; 23: 1256-1261
        • Valenzuela M.J.
        • Sachdev P.
        Brain reserve and cognitive decline: a non-parametric systematic review.
        Psychol Med. 2006; 36: 1065-1073
        • Dijkstra J.B.
        • Van Boxtel M.P.
        • Houx P.J.
        • et al.
        An operation under general anesthesia as a risk factor for age-related cognitive decline: results from a large cross-sectional population study.
        J Am Geriatr Soc. 1998; 46: 1258-1265
        • Abildstrom H.
        • Rasmussen L.S.
        • Rentowl P.
        • et al.
        Cognitive dysfunction 1–2 years after non-cardiac surgery in the elderly. ISPOCD group. International Study of Post-Operative Cognitive Dysfunction.
        Acta Anaesthesiol Scand. 2000; 44: 1246-1251
        • Billig N.
        • Stockton P.
        • Cohen-Mansfield J.
        Cognitive and affective changes after cataract surgery in an elderly population.
        Am J Geriatr Psychiatry. 1996; 4: 29-38
        • 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
        • 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
        • Goldstein M.Z.
        • Fogel B.S.
        • Young B.L.
        Effect of elective surgery under general anesthesia on mental status variables in elderly women and men: 10-month follow-up.
        Int Psychogeriatr. 1996; 8: 135-149
        • Newman M.F.
        • Kirchner J.L.
        • Phillips-Bute B.
        • et al.
        Longitudinal assessment of neurocognitive function after coronary-artery bypass surgery.
        N Engl J Med. 2001; 344: 395-402
        • Avidan M.
        • Searleman A.
        • Storandt M.
        • et al.
        Long-term cognitive decline in elderly people was not attributable to non-cardiac surgery or major illness.
        Anesthesiology. 2009; 111: 964-970
        • Ancelin M.L.
        • de Roquefeuil G.
        • Ledesert B.
        • et al.
        Exposure to anaesthetic agents, cognitive functioning and depressive symptomatology in the elderly.
        Br J Psychiatry. 2001; 178: 360-366
        • Leung J
        • Sands L
        • Mullen E
        • et al.
        Are preoperative depressive symptoms associated with postoperative delirium in geriatric surgical patients?.
        J Gerontol A Biol Sci Med Sci. 2005; 60: 1563-1568
        • Leung J.M.
        • Sands L.P.
        • Vaurio L.E.
        • et al.
        Nitrous oxide does not change the incidence of postoperative delirium or cognitive decline in elderly surgical patients.
        Br J Anaesth. 2006; 96: 754-760
        • Leung J.M.
        • Sands L.P.
        • Paul S.
        • et al.
        Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients?.
        Anesthesiology. 2009; 111: 625-631
        • Vaurio L.
        • Sands L.
        • Wang Y.
        • et al.
        The role of pain and medications on postoperative delirium.
        Anesth Analg. 2006; 102: 267-273