Postop Cognitive Dysfunction Rises With Age

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER

MIAMI BEACH — With the aging of the U.S. population, hospitalists increasingly act as perioperative geriatricians and manage the unique challenges of this population, including increased cognitive dysfunction and delirium.

“Acute hospital care is becoming acute geriatric care,” Dr. Robert M. Palmer said. People aged 65 years and older accounted for 13% of the U.S. population and 38% of hospital discharges in 2005, according to a report based on data from the National Hospital Discharge Survey (Vital Health Stat. 13. 2007;165:1–209).

“There is something very different about these elderly perioperative patients,” said Dr. Palmer, clinical director of the division of geriatric medicine and gerontology, University of Pittsburgh.

Cognitive dysfunction is more common than delirium among elderly patients, but the two conditions are part of the same spectrum, Dr. Palmer said at a meeting on perioperative medicine sponsored by the University of Miami.

In a study of patients undergoing major noncardiac surgery, postoperative cognitive dysfunction occurred in 41% of patients aged 60 years and older, 37% of patients aged 18-39 years, and 30% of those aged 40–59 (Anesthesiology 2008;108:18–30).

For example, an 82-year-old woman who has been independent in all activities of daily living prior to a hip fracture “is at high risk, greater than 40%, of postoperative cognitive dysfunction” after hip surgery, Dr. Palmer said. “We don't totally understand the etiology.”

A meeting attendee asked about quick assessment of cognitive function. “Ask [the patients] about activities of daily living—have they been able to pay bills, do finances, and take medication without assistance?” Dr. Palmer said. Also ask patients or family members about history of memory loss. Also consider a bedside digit span test. “Ask them to repeat a random string of numbers. Give them the numbers 1 second apart in a monotone,” he said. “Someone with delirium can only repeat three or fewer numbers.”

Cognitive dysfunction can be long-lasting in some patients. “Even at months after surgery, 13% [of those aged 60 and older] had signs of postoperative cognitive dysfunction versus none in an age-matched control group,” he said. None of the younger or middle-aged patients had cognitive dysfunction at 3 months.

In contrast, postoperative delirium is more likely to last only 24–72 hours after surgery (Anesthesiology 2007;106:622–8). This disorder of attention and cognition also can exist preoperatively and/or emerge in the recovery room.

Predictors of delirium following elective surgery include age 70 or older, alcohol abuse, baseline cognitive impairment, severe physical impairment, abnormal preoperative electrolyte or glucose levels, abdominal aortic aneurysm surgery, and noncardiac thoracic surgery (JAMA 1994;271:134–9). Risk was 2% in patients with none of these predictors, 11% among those with one or two risk factors, and 50% in patients with three or more risk factors.

Anticholinergics, benzodiazepines, and meperidine can increase the risk of postoperative delirium, according to consensus data (Arch. Intern. Med. 2003;163:2716–24). “These agents, generally speaking, should be avoided in all elderly patients,” Dr. Palmer said.

In addition to cessation of any high-risk medication, the use of supplemental oxygen, adequate nutritional intake, and ambulation on postoperative day 1 can reduce the risk of postoperative delirium. It is also important to treat any severe pain, he said. “Patients who are in pain cannot participate in physical therapy, so you need to address pain before you do everything else.

'There is something very different about [the responses of] these elderly perioperative patients.' DR. PALMER