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Contin Educ Anaesth Crit Care Pain-2006-Fines-37-40
Contin Educ Anaesth Crit Care Pain-2006-Fines-37-40
doi 10.1093/ceaccp/mki066
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 1 2006 37
ª The Board of Management and Trustees of the British Journal of Anaesthesia [2006].
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Cognitive disturbance in the elderly
Table 1 Aspects of cognitive function tested by the MiniMental State Examination the lay person’s view of POCD. It is difficult to get a reliable
estimate of how prevalent and disabling such conditions are.
Orientation in time
Orientation in place Hence the approach used by the investigators in the International
Repetition of named objects Study of Postoperative Cognitive Dysfunction to define the
Repetition of simple phrase
condition in terms of a statistical abnormality, rather than any
Ability to undertake simple arthmetic
Recall of objects named earlier in the interview particular clinical features.
Naming of objects shown by examiner Research into POCD is fraught with problems. Observed over
Execution of simple tasks by written and spoken command
time, a proportion of the elderly population will suffer cognitive
Writing a simple sentence
Copying a simple design decline in any event, and some studies are hampered by the lack
of an appropriate control group. Also, the development of other
pathologies within the study period may affect the results. The
progress following illness or surgery. The MMSE is scored out of a tests used to detect POCD vary among studies, making compar-
total of 30, with points being awarded for correct answers in the ison difficult. The level of difficulty of the tests themselves is
various aspects of function tested. An MMSE score of <23 is not important—too easy and they fail to detect more subtle degrees
diagnostic of dementia but does offer supporting evidence. Lesser of impairment, too difficult and they discourage the subject, thus
38 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 1 2006
Cognitive disturbance in the elderly
however, that biochemical disturbances cause prolonged POCD. longed POCD (from 9.9 to 5%). This is thought to be the result of
Perhaps more surprisingly, there is no evidence that perioperative a deterioration in patients who have such medication withdrawn
hypoxaemia or hypotension, even quite profound or prolonged, is acutely, rather than a direct protective effect of the drug. Certainly
associated with POCD.6 patients who are taking drugs to support their cognitive function,
including the anticholinesterase drugs such as donezepil, should
Pre-existing cognitive impairment not have them stopped perioperatively. There are grounds to
Studies of POCD exclude patients who are already cognitively believe that sudden stopping of anticholinesterases may precipit-
impaired, but it is possible to demonstrate a lower risk of ate cognitive failure that may be difficult to reverse.
POCD in patients with a higher level of intellectual performance
preoperatively. It is likely that the converse is true and a pre- Conduct of anaesthesia
existing dysfunction increases the risk of POCD.
There is no strong evidence to support the use of any particular
drugs. However, there are significant associations between early
Other factors POCD, and both increasing duration of anaesthesia and respir-
Serum concentrations of known markers of brain damage such as atory complications; therefore attention can be directed to the
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 1 2006 39
Cognitive disturbance in the elderly
40 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 1 2006