Background: Postoperative cognitive dysfunction (POCD) causes an increase in social and economic burdens because of the prolonged length of stay in the hospital, increased costs, and decreased quality of life. No data on POCD has ever been recorded in Indonesia. The goal of this study was to determine the incidence of POCD in elderly people at Sanglah General Hospital, Indonesia. Patients and Methods: This is a descriptive study conducted at Sanglah General Hospital in 2018. Inclusion criteria included patients of 60 years old or more who came to anesthesia preoperative clinic with the American Society of Anesthesiologists physical status 1 and 2. Cognitive functions were assessed three times: 1 day before the surgery, 2 days after the surgery, and 4 weeks after the surgery. POCD was defined as an at least 20% decreased result of two out of three instruments used. Results: The study included 84 participants consisting of 52 males and 32 females. The mean age was 66.0 ± 5.1 years. Most participants were elementary school graduates (34.5%) and high school graduates (27.4%). There were 7 (8.3%) patients who developed POCD within 48 h and 4 weeks postoperatively. Conclusion: The incidence of POCD at Sanglah General Hospital was 8.33% both at 48 h and 4 weeks postoperatively.
Keywords: Incidence, Indonesia, postoperative cognitive dysfunction, surgery
|How to cite this URL:|
Parami P, Ryalino C. The incidence of postoperative cognitive dysfunction in elderly patients underwent elective surgery at Sanglah General Hospital. Bali J Anaesthesiol [Epub ahead of print] [cited 2021 Apr 22]. Available from: https://www.bjoaonline.com/preprintarticle.asp?id=295202
| Introduction|| |
Postoperative cognitive dysfunction (POCD) refers to decreased reversible cognitive function that is associated with surgery. POCD causes an increase in social and economic burdens because of the prolonged length of stay in the hospital, increased costs, and decreased quality of life.,,
Age is an independent risk factor that is significant for POCD events. A study showed that the younger age groups significantly showed less POCD incidence on the 7th day (P = 0.0064) and in 3 months (P = 0.026) after surgery compared to groups aged 60 years over. Another study reported that after 3 months, the incidence of POCD in the young (5.7%) and middle age (5.6%) groups was significantly lower compared to the old age (12.7%) group.
Based on the Indonesian health-care database, the number of elderly people (≥60 years old) based in 2010 was 18.1 million or 7.6% of its total population. This number is estimated to reach 36 million by 2025 with an increased incidence of degenerative diseases; elderly people often need surgery and anesthesia. Therefore, the risk of POCD is expected to be increased in the near future.
Sanglah General Hospital is the largest government hospital in Bali Island. It is the referral hospital for the eastern part of Indonesia. Up until now, no data on POCD has ever been recorded in Indonesia. This study was conducted to determine the incidence of POCD in elderly people and their characteristics at Sanglah General Hospital of Bali, Indonesia.
| Patients and Methods|| |
This is a descriptive study conducted at Sanglah General Hospital in 2018. A total of 84 participants were enrolled in the study. This study was approved by the Committee of Ethical Research of Udayana University/Sanglah General Hospital. All enrolled participants provided written informed consent to be included in the study.
Demographic data of this study were taken from the medical record. They included age, gender, current address, and education background. Cognitive functions were assessed using three instruments: mini-mental status examination (MMSE), the Indonesian version of Montreal Cognitive Assessment (MOCA-INA), and activity daily living. Both MMSE and MOCA-INA are routinely used at the Neurobehavior Clinic of Neurology Department, Sanglah General Hospital.
Inclusion criteria included patients of 60 years old or more who came to anesthesia preoperative clinic with the American Society of Anesthesiologists physical status 1 and 2, whereas exclusion criteria included patient who was letter blind or unable to read/write, patients with abused drugs or alcohol history, patients who were unable to follow the instruments used, patients who underwent heart or brain surgery, and patients with a previous history of cerebrovascular accidents or other central nervous system disorders.
Cognitive functions were assessed three times: 1 day before the surgery, 2 days after the surgery, and 4 weeks after the surgery. For the purpose of this study, POCD was defined as an at least 20% decreased result of two out of three instruments used.
Data analysis was done descriptively. Kolmogorov–Smirnov test was used for normality test. Normally distributed numerical data were presented in mean ± standard deviation, whereas median and interquartile range were used for the opposite. Categorical data were displayed in relative frequency. All data were analyzed using SPSS version 25 software (IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY, USA: IBM Corp.).
| Results|| |
The study included 84 participants consisting of 52 males and 32 females. The mean age was 66.0 ± 5.1 years. Most participants were elementary school graduates (34.5%) and high school graduates (27.4%). This may be related that, back in the past, a mandatory educational program had not been enforced in Indonesia. The mean duration of anesthesia was 129.7 ± 82.1 min, with 50 participants underwent general anesthesia and the rest underwent regional anesthesia. None of the participants involved experienced surgery-related complications intraoperatively and postoperatively. A complete characteristic of the participants is displayed in [Table 1].
By defining POCD as an at least 20% decrease of cognitive tests in at least two out of three instruments used, we found that 7 (8.3%) patients developed POCD within 48 h postoperatively. This number is not changed after reevaluating the participants again 4 weeks after the surgery [Table 2].
| Discussion|| |
In our study, the incidence of POCD was 8.33% at 48 h postoperatively, and the incidence was similar at 4 weeks postoperatively. These numbers resembled to other previous studies in various countries.,,,
POCD is still a challenge for clinicians and practitioners. There have been many studies that try to find the cause of this incident, but none were able to conclude the exact cause of this incident. Research on POCD has been developing since the 1990s. The ISPOCD-1 study showed that there is no relationship between the state of hypoxia and hypotension against the occurrence of POCD. Several factors that are thought to play a role including age, duration of anesthesia, complications during surgery, and postoperative infection are estimated as factors that influence the occurrence of POCD.,,,
The first large prospective study describing postoperative cognitive decline after noncardiac surgery was published by a multinational research group in 1998. Patients aged 60 years or older who underwent major abdominal and orthopedic surgeries completed a series of psychometric tests before surgery and at 1 week and 3 months after surgery. Cognitive dysfunction occurs in 25% of hospital discharge patients, and 10% had cognitive changes measured at 3 months after surgery. Old age is the only significant predictor for POCD 3 months after surgery. Using the same research design, Monk and Price  evaluated adults of all ages undergoing major noncardiac surgery and diagnosed POCD in 30%–40% of adult patients of all ages in the hospital. Independent risk factors for POCD include older age, low education level, and history of cerebral vascular accidents without residual disorders. Some studies also found that POCD was associated with an increased risk of death in the 1st year after surgery.
The etiology of POCD is still not fully determined clearly, but it is thought to be caused by damage to brain cells caused by toxic substances, which can originate from anesthetic drugs. It can also arises due to the body's response to surgery that causes hormone release and pro-inflammatory mediators. The pathogenesis of POCD remains unclear, but several factors thought to be influential including age, alcohol abuse, low basic cognition, hypoxia, hypotension, and type of surgeryhave been thought to contribute to this problem. Anesthetic drug selection can also affect postoperative cognition because volatile anesthetic residual levels can produce changes in central nervous system activity.,
General anesthesia by administering anesthetics that affect several target organ system in the central nervous system is suspected to be one of the factors that can increase the morbidity of patients and the incidence of postoperative cognitive function disorders, but more research needs to be done in more depth on the influence of drug anesthetic medicine for this incident.,,
| Conclusion|| |
The incidence of POCD at Sanglah General Hospital was 8.33% both at 48 h and 4 weeks postoperatively. Further large-scale studies must be conducted to fully understand the nature of POCD in the hope of preventing or decreasing the incidence in the future.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth 2009;103 Suppl 1:i41-46.
Borozdina A, Qeva E, Cinicola M, Bilotta F. Perioperative cognitive evaluation. Curr Opin Anaesthesiol 2018;31:756-61.
Hanning CD. Postoperative cognitive dysfunction. Br J Anaesth 2005;95:82-7.
Ramaiah R, Lam AM. Postoperative Cognitive Dysfunction in the Elderly. Anesthesiol Clin 2009;27:485-96.
Steinmetz J, Christensen KB, Lund T, Lohse N, Rasmussen LS, ISPOCD Group. Long-term consequences of postoperative cognitive dysfunction. Anesthesiology 2009;110:548-55.
Kusumawardani N, Tarigan I, Suparmi, Schlotheuber A. Socio-economic, demographic and geographic correlates of cigarette smoking among Indonesian adolescents: Results from the 2013 Indonesian Basic Health Research (RISKESDAS) survey. Glob Health Action 2018;11:1467605.
Rasmussen LS. Postoperative cognitive dysfunction: Incidence and prevention. Best Pract Res Clin Anaesthesiol 2006;20:315-30.
Wang W, Wang Y, Wu H, Lei L, Xu S, Shen X, et al
. Postoperative cognitive dysfunction: Current developments in mechanism and prevention. Med Sci Monit 2014;20:1908-12.
Funder KS, Steinmetz J, Rasmussen LS. Cognitive dysfunction after cardiovascular surgery. Minerva Anestesiol 2009;75:329-32.
Glumac S, Kardum G, Karanovic N. Postoperative Cognitive Decline After Cardiac Surgery: A Narrative Review of Current Knowledge in 2019. Med Sci Monit 2019;25:3262-70.
Moller JT, Cluitmans P, Rasmussen LS, Houx P, Rasmussen H, Canet J, et al
. Long-term postoperative cognitive dysfunction in the elderly ISPOCD1 study. ISPOCD investigators. International Study of Post-Operative Cognitive Dysfunction. Lancet 1998;351:857-61.
Androsova G, Krause R, Winterer G, Schneider R. Biomarkers of postoperative delirium and cognitive dysfunction. Front Aging Neurosci 2015;7:112.
Evered L, Scott DA, Silbert B, Maruff P. Postoperative cognitive dysfunction is independent of type of surgery and anesthetic. Anesth Analg 2011;112:1179-85.
Monk TG, Price CC. Postoperative cognitive disorders. Curr Opin Crit Care 2011;17:10.
Department of Anesthesiology and Intensive Care, Faculty of Medicine, Udayana University, Jl. Pb Sudirman, Denpasar 80232, Bali
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2]