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Current aspects in postoperative cognitive dysfunctions, including otolaryngological procedures.

INTRODUCTION

A common and clinically important complication of surgery is postoperative cognitive dysfunction, or POCD. POCD is a mild form of ischemic brain damage that occurs in the postoperative period and is characterized by impaired concentration and memory problems, which may persist for months or even years after the surgery. Studies of POCD are extensive, encompassing multiple surgical specialties ranging from cardiac surgery to minor outpatient interventions. Significant well-known risk factors for the development of POCD include: type of surgery, duration and type of anesthesia administered during surgery, advanced patient age, history of alcohol abuse, and use of anticholinergic medications. At present, the incidence of POCD is difficult to determine because formal criteria for [TEXT UNREADABLE IN ORIGINAL SOURCE] diagnosis and evaluation are lacking. Many studies have attempted to systematize the definition of POCD [TEXT UNREADABLE IN ORIGINAL SOURCE] its [TEXT UNREADABLE IN ORIGINAL SOURCE]. There is general agreement that POCD consists of subtle disruptions of thought processes, which [TEXT UNREADABLE IN ORIGINAL SOURCE] a significant impact on the patient's health; however, a precise definition is yet to be established.

Early POCD, i.e. that which is observed within the first few days of surgery, has previously been assessed using the Post-operative Quality of Recovery Scale [1], The results of this study indicate that although the disorder is transient in nature, for most patients the cognitive impairment fails to resolve within 3 days post-surgery.

Previous POCD studies focused on cardiac surgery because, until recently, cognitive impairment after cardiac surgery was considered to result from physiological disturbances associated with the cardiopulmonary bypass technique. In 2011, a study was conducted in 644 patients, which indicated that cardiac surgery and associated procedures were principal predictors of early (up to 7 days after surgery) POCD [2], Research has since shown that the immune system is a key element in the pathogenesis of POCD after cardiac surgery [3]. Also in support of this hypothesis, are the findings of a recent study that suggest inflammatory neuronal changes may be fundamental in the mechanism of postoperative cognitive dysfunction [4], The relationship between the choice of anesthesia and the occurrence of POCD has also been studied, and epidural anesthesia was Ibund to be safer and less likely to result in POCD than general anesthesia [5].

There are increasing possibilities for a large number of minor surgical interventions to be carried out on an outpatient basis. Although the benefits of such procedures are well established, outpatient surgery presents another challenge: the expectation of prompt recovery soon after surgery. Cognitive complications, including delirium and POCD, have been reported to be less common in outpatient surgery [6],

Interestingly, the type of anesthesia used has also been hypothesized to influence the development of POCD. However, previous studies, including those specifically related to outpatient interventions, failed to provide sufficient evidence to conclude whether intravenous anesthesia (propofol) vs. inhalational reduces the risk of delayed cognitive dysfunction [7], Cerebral oxygen saturation (SC02), which represents oxygen balance in the brain, has also been shown to be an effective prognostic factor for POCD [8].

The frequency of perioperative cognitive dysfunction (POCD) in orthopedic patients varies from 16% to 45% [9]. Certain studies indicate that the possibility of monitoring patients using near infrared spectroscopy (NIRS) during lumbar spine surgery in a prone position may be helpful in reducing the risk of POCD.

Current techniques and physician awareness of POCD risk are expected to increase pressure on the need for optimization of surgical and anesthesiological procedures. In the current article we review the literature related to POCD, with a particular focus on specific risk factors in otolaryngological surgery.

Definition and differential diagnosis

POCDs are transient clinical phenomena defined by Bedford as "adverse cerebral effects of anesthesia on old people" [10]. In 2008, Chung and Assmann published case studies of two young people with POCD, confirming that POCD may in fact occur at any age [11]. After ambulatory surgeries, these patients caused serious road accidents in the direct postoperative phase. According to recent data, 40% of patients older than 60 years of age suffer from POCD after surgery; however, in the 3 months following surgery only 10% of patients older than 60 are diagnosed with POCD [12], Impairments in attention, memory, executive functions, and some verbal functions extends the recovery period after surgery and negatively affects the patient's ability to function effectively in family and society. Nowadays, as the result of the development of modern surgical techniques, which enable doctors to carry out extensive surgeries in increasingly older patients, POCD is likely to occur much more frequently.

[TEXT UNREADABLE IN ORIGINAL SOURCE] functions are mental activities used for spatial orientation, to acquire information about oneself, to analyze situation. to formulate conclusions, and to make decisions and execute action[13]. TTie most frequent [TEXT UNREADABLE IN ORIGINAL SOURCE] in the course of POCD are memory and spatial orientation disturbances, as well learning, thinking [TEXT UNREADABLE IN ORIGINAL SOURCE] and speech disorders. POCD must be distinguished from delirium, central anticholinergic syndrome, dementia, and akinetic crisis [14].

Epidemiology

Most studies of POCP published to date relate to cardiac surgery, particularly that requiring, cardiopulmonary bypass. Current research on the effects of anesthesia on cognitive abilities focuses on: the type of anesthesia, whether it is local or general, duration, ana type of formulation used. The age of respondents and.their preoperative cognitive functioning also is also of interest.

Data concerning the incidence of POQD vary, since they depend orilhe definition of POCD, the patient . sample and control group, the measurement method used, andthe methop pf statistical evaluation [14-16]. Krenk [17] presented data showing that POCD may refer to all age groups,. but in patients older than. 60, the symptoms persist longer and lead to the limitation of normal activity. Monk[18] reported that on the day of hospital discharge, POCD had been diagnosed in 36.6% of patients aged 18-39, 0.4% of those 40-59 years old, and 41.4% of patients older them 60. All patients nad undergone extensive surgeries (i.e. surgery scheduled under general anesthesia that was expected to last 2 h or longer); however, none underwent cardiac surgery. Three months after discharge, POCD was still reported in 12.7% patients older than 60. Previous stpdies.reported that a higher incidence of the disorder is typically observed in certain patient groups, e.g. those with cardiovascular disease or subclinical dementia [19-21].

Many years pf research has confirmed that POCD is a temporary phenomenon, In most patients diagnosed witn POCP, cognitive impairment lasts for up to 3 months anertlfe operation. For the minority of patients, POCD symptoms may be sustained for far longer, potentially becoming a permanent condition which will have a major impact on quality of life. Steinmetz [221 documented, following an 8.5-year study, that POCD is correlated with increased mortality rate, disability leading to premature disability benefits, anc| additional social encumbrances for society. If is important to identify early signs of cognitive impairment, Monk[18] also reported risk of death is increased if POCD was observed when patients were being discharged from hospital (Cox proportional Hazard Ratio 1.63).

Diagnostic methods

POCD is diagnosed using psychometric tests. The recommendations of the 1995 consensus indicate the results of several tests should be considered in the diagnostic process, ana these are described in Table l. In long-term studies, tests such as the Stroop Test, paper ana pencil memory tests, or fourfold tests are typically used [23]. Interestingly, there is evidence to suggest that the selection of tests and the order in which they are administered, may have a significant impact on study outcomes [24]. It is recommended that tests evaluating, the revel of predisposition to anxiety and depression be used in parallel, as these conditions may subsequently affect cognitive function.

Full neuropsychological assessment often lasts more than 2hours. This presents another difficulty, as the stress associated witn surgery can falsify the actual performance level of cognitive ability [25].

The Short Cognitive PerformanceTest (SKT) is a potential alternative [26]: it can be performed within 15 minutes and is based on the speed of processed information. It examines changes in cognitive abilities such as attention, concentration, and memory. The test is simple and attractive, and is therefore greatly popular among researchers[27]. Chung [28] uses a driving simulator to gain quick diagnostics of cognitive disturbances.

The Post-operative Quality of Recovery Scale (PQRS) is also used in many studies. The Postop QRS is a measurement tool to assess many factors influencing the post-surgical convalescence [29,30]. It is a frequently used method, which takes only 5 to 6 minutes to conduct. The results obtained from this survey show the condition of the patient, but cannot be used to indicate the presence of neuropsychological disorders.

Pathogenesis and risk factors for POCD

The mechanism underlying the development of cognitive dysfunctions after a surgery and anesthesia is not clear. As mentioned above, animal experiments indicate, that the immune response occurring as a result of surgery may play a role. In a study, of mice ungergoing surgery. Terrando [31] proved that the activation of the TNF[alpha]/NF-[kappa]B-dependent inflammatory cascade and consequent cytokine release leads to a disturbance of the integrity of the blood-brain barrier. This facilitates macrophage migration, to the hippocampus and results in a weakening of memory functions, Both TNF[alpha] (tumor necrosis factor) and NF-[kappa]B (a protein complex that acts as a transcription factor) play a Key role in regulating the immune response fo infection[32]. The study also demonstrated that activation of anti-inflammatory anticholinergic signal cascade blocks this mechanism and cognitive functions remain unimpaired.

Clinical observations indicate that POCD more often occurs after extensive surgeries in which general anesthesia was used, after re-surgery, and following operative complications. These observations support the idea that the inflammatory component is a significant factor in the development of cognitive disorders.

The impact of the drugs used in general anesthesia on cognitive functions depends on the pharmacodynamics and pharmacokjnetics of these substances; however, what is clear is me shorter the drug action, the shorter the duration of POCD immediately after surgery. At present, there is no evidence to suggest that these drugs cause "chronic" POCD. Twin studies, have not provided any evidence of neurotoxicity of the applied anesthetics [33]; in addition, there are no data proving that POCD occurs less Frequently following local anesthesia, as compared to general anesthesia.

[TEXT UNREADABLE IN ORIGINAL SOURCE] patient's age is a very important rish factor for POCD. The apility of the cehtrat nervpus system to compensate in response to anesthesia decreases with age. Imaging examinations performed in elderly people often reveal ischemic foci without clinical symptoms (silent brain ischemia), which is predisposes these patients to POCD.[34]. Another risk factor is alcohol abuse, as shown By Hudetz [35] in a randomized study. Low education level also corresponds to high likelihood of POCDs [23, 36], The significance of genetic factors is also a subject of discussion [16].

Prevention of POCD

When assessing the need for extensive surgeries, especially in elderly people, the benefits and potential negative consequences should always be properly balanced and the potential occurrence of POCD should be taken into account. In such situations it is useful to determine the patient's preoperative cognitive status.

POCD occurs more often and is more intensive after extensive surgeries (e.g. cardiac surgery, using cardiopulmonary by bass). To try to prevent cognitive disorders, it is important to prevent intra- and postoperative complications. To what extent minimally invasive surgical techniques prevent cognitive disorders has not yet beeh studied; however, hypothetically, less tissue injury is associated with less, inflammatory reaction and thus should correlate with a reduction in cases of cognitive dysfunctions [18,37]. As mentioned above, generally, it is assumed that the shorter action of the anesthetic, the shorter the duration of POCDs. Remembering this, we should critically, analyze the present premedication practice; for example, midazolam (dormicum), which may result in cognitive disorders. In his publication, Dressler [33] demonstrated that after 1 or 2 hours of general anesthesia with propofol/remifentanil and premedication with midazolam, memory disorders occurred on the first day after surgery [38]. With regard to the modern concept of perioperative proceedings, which assumes early patient cooperation after the surgery (fast-track treatment), the above-mentioned limitations of cognitive fuhctions receiver negative evaluation. On the other hand, we still do not have evidence that techniques other than general anesthetics reduce the incidence of POCD [39].

In many areas of surgery, progress is connected with the development of endoscopic techniques, which often create special requirements for general anesthesia. Endoscopic transnasal surgery, in which bleeding during the surgery must be kept low, is a special challenge, Little bleeding and good visibility in the operating field has been achieved by maintaining a low heart rate (HR) and gradually lowering the mean arterial blood pressure (MAP) [40]. The anesthetics used in such endoscopic surgeries were propofol andremifentanil or sevoflurane and esmolol[41]. The influence of controlled, hypotension during endoscopic procedures on middle cerebral artery peak systolic velocity was additionally evaluated when good, bloodless conditions of the operating field were achieved [42]. More than half of patients operated standard flow rate fell below the lower limit of normal and end-diastolic velocity was below the limit of even 60% of patients in these conditions, as is apparent from earlier studies could be a risk of ischemic brain tissue. Previous studies have demonstrated a correlation between middle, cerebral artery peak systolic velocity and cerebral blood flow;, as such, it is possible that increased risk of cerebral ischemia might have occurred in these conditions. No neurological disturbances were found in any of the patients in the postoperative period; however, cognitive functions need to be monitored in patients who have undergone this kind of surgery. Other works by the same research team, indicate that lowering the middle cerebral artery peak systolic velocity was directly caused by a reduction of the hemodynamic parameters of the cardiovascular system, not the set of drugs used for general anesthesia. Although lowered RR (blood pressure) and HR (Heart Rate) parameters were maintained within the limits commonly regarded as safe, the blood flow velocity occasionally dropped below the lower limit of the normal range and blood flow velocity parameters lowered unevenly, which (according to some scholars) may prove approximating the phase of failure of cerebral blood [TEXT UNREADABLE IN ORIGINAL SOURCE] autoregulation mechanisms [43]. In another study [44], the serum concentration of S-100 and [TEXT UNREADABLE IN ORIGINAL SOURCE] Neuron-specific enolaze) protein was evaluated, as these are considered to be markers of nervous tissue injury. Increased concentration of NSE was found in 5 of 6 patients who had a drop of middle cerebral artery peak systolic velocity below the lower limit of the normal range. Although neurological complications were not observed, the results or the presented studies point to the need to evaluate the possibility of POCD occurring in patients treated with transnasal endoscopic surgery. In this cage, POCD maybe connected not with the extensiveness of the operation but rather with potential hemodynamic disorders and perfusion.

Developments in the cerebral circulation during, several hours of free maintenance of heart function and hypotension should be the subject of further studies. Could rate evaluating the safety margin used methods of intraoperative anesthesia, and their impact on the further functioning of the patient. It is important that future studies on this disorder focus on measures to prevent the occurrence of POCD. Although many studies have attempted to elucidate whether electroencephalography (EEG) monitoring of the depth of anesthesia may contribute to limiting POCD. [45,46], to date this question remains unanswered and should be the subject of future studies.

CONCLUSIONS

POCD is both widespread and common. Its occurrence depends on a variety of factors. POCD is difficult to define and the exact investigational strategy remains uncertain due to the extensiveness of the phenomenon. Most studies conducted so far agree that the risk of POCD increases concurrently with the patient's old age, diseases of central nervous system, cardiovascular disorders and extensive surgery. POCD is a temporary postoperative disorder and correlates with poorer recovery after the surgery. Importantly, careful anesthesiological and surgical procedures lowers the likelihood of POCD. The dynamically developing area of minimally invasive surgery, especially endoscopic transnasal surgery in which a "dry" operating field is required, calls for research into the occurrence of POCD following this type of surgery and methods of prevention. The management strategy for POCD should be multimodal, and invelvs close cooperation of the anesthesiologists, surgeons, geriatric specialists, psychologists and the patient's family members. Ibis network will promote early rehabilitation and a\oid loss of autonomy by postoperative patients. Future clinical research should concentrate on factors that are likely to provide a better understanding of POCD.

Conflicts of interest

The authors declare no conflicts of interest. Funding

No sources of support provided.

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Rogowska A. *, Wygnat N. (1), Simonienko K. (1), Kwiatkowski M. (1), Kuryga D. (2)

(1.) Department of Psychiatry, Medical University of Biatystok, Poland

(2.) Department of Otolaryngology, Medical University of Biatystok, Poland

* Corresponding author:

Department of Psychiatry

Medical University of Biatystok

16-070 Choroszcz, Poland

Tel.:/ Fax: +48857193977; e-mail: anna_rogowska@o2.pl

Received: 19.08.2015

Accepted: 1.12.2015
Table 1, Methods used in neuropsychological
evaluation

Test              Definition

Rey               Assesses the level
Auditory          of verbal learning
Verbal            and memory. It
Learning          gained great
Test              popularity due to
                  the simplicity and
                  ease of testing and
                  comprehensibility
                  for most age
                  groups.

Trail             Assesses
Making            concentration,
Test: A and       divisibility, mental
B (TMT)           flexibility and
                  variability
                  comments.

Grooved           A test of manual
Pegboard          dexterity and motor
Test              coordination.

Digit Span        Assesses the
Test              capacity and
                  efficiency of
                  working memory.

Wisconsin         Measures
Card              executive function,
Sorting           understood as
Test              human oversight
(WCST)            functions.

Stroop Test       The original
                  version tests
                  reading speed,
                  verbal memory and
                  executive
                  functions.
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Author:Rogowska, A.; Wygnat, N.; Simonienko, K.; Kwiatkowski, M.; Kuryga, D.
Publication:Progress in Health Sciences
Article Type:Report
Date:Dec 1, 2015
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