老年患者术后认知功能障碍.ppt

1、Postoperativecognitivedysfunctioningeriatricpatients,Delirium, dementia, and POCDIncidence and diagnosisPotential mechanisms of POCDRisk factorsPrevention and prophylaxisConclusion,Postoperative cognitive dysfunction (POCD) is frequently seen after surgical procedures. POCD is a serious complication

2、 and is characterized by a functional decline which may persist for months .,术后认知功能障碍（POCD）是外科手术术后常见的并发症，其特征是持续数月的功能下降。尤其是老年患者，其生理上发生改变，对于手术，麻醉及一般住院带来的压力的能力减弱 ，而且老年患者越来越多，POCD更引起人们的关注。,Delirium, dementia, and POCD,POCD is often confused with dementia or acute postoperative delirium. POCD经常与老年痴呆及急性术后

3、谵妄相混淆 。,Postoperative delirium is frequently seen following a surgical procedure and has been defined as an acute change in mental status, with inattention and fluctuating reduced levels of consciousness over 24 h. The majority of postoperative delirium cases occur between days 1 and 7 after the ope

4、ration.,术后谵妄是常见于外科手术后，已被定义为一种急性精神状态的改变，表现为注意力不集中和波动性意识水平下降超过24小时，常发生于术后1到7天。,Dementia, in contrast, is a chronic, irreversible progressive disease that affects mostly older adults, often exists prior to surgery and anesthesia. Memory impairment is one of the hallmarks of dementia.,与此相反，痴呆是一种慢性的，不可逆的

5、渐进性的疾病，主要影响的是老年人，往往存在于手术和麻醉前，记忆力障碍是老年痴呆症的标志之一 。,POCD is characterized by a long-term stable cognitive impairment, which is considered to be reversible, but may persist up to months after surgery. POCD can be differentiated from postoperative delirium, since POCD has a longer duration and no fluctuat

6、ions in impaired cognitive functioning.,POCD的特征在于，它是一个长期稳定的认知功能障碍，这种认知功能障碍被认为是可逆的，但可能会持续到手术后几个月。 POCD可以与术后谵妄相鉴别，是因为POCD持续很长一段时间并且没有认知功能受损的波动性。,Incidence and diagnosis,The exact incidence of POCD is unknown. In clinical practice, patients are currently only tested after surgery, if there is a suspici

7、on of POCD. Therefore, the current incidence rates are an underestimation.,diagnosis,POCD的诊断主要是认知能力测试。在过去的几十年里，神经心理测验已被用来测量病人的认知能力。多个测试可用来评估不同领域的认知功能障碍，如定向力，记忆力，执行能力等，然而，所有的测试都有其局限性，现在测试评估POCD的方式还没有达成共识。,Potential mechanisms of POCD,The etiology of POCD is still unknown. However, over the last decad

8、e multiple studies have been performed on this topic. POCD的病因仍然未知，然而已经提出了几个关于POCD发展的途径。,外科手术导致系统性的应激反应，释放神经内分泌激素及炎症因子，这些细胞因子可能使脑功能发生改变并促进POCD的发展；POCD经常发生在心脏手术的病人，可能与术后过度复温有关；血清中S-100蛋白浓度的增加可促进POCD的发展；大脑细胞凋亡是POCD的一个潜在机制。,Risk factors for POCD,Surgery-related risk factorsCardiac surgery Major and inva

9、sive surgeryLong operation durationPostoperative complications Patient-related risk factorsIncreased ageHistory of alcohol abusePrevious POCDHistory of strokeHigher ASA classification,教育程度与POCD,The lower educational level fits with the “threshold” theory for cognitive decline: if a patient has a low

10、er educational level, he/she is more vulnerable to cognitive decline. A small decline may, therefore, result in cognitive impairment, while patients with a higher educational level still might be on a normal cognitive functional level even after a cognitive decline,教育程度较低，适合于认知功能下降的“门槛”理论：如果病人有较低的教育

11、水平，他/她更容易产生认知能力下降，一个小的下降可能会导致认知功能障碍，而患者具有较高的教育水平即使在认知能力下降时，其仍然可能在一个正常的认知功能水平。,Other risk,The use of benzodiazepines，the dosage of fentanyl and different volatile anesthetics did not affect the occurrence of POCD. Hypoperfusion or hypoxia of the brain due to blood loss, systemic hypotension, or hypox

12、ia have been thought to be potential causes of POCD in the perioperative period .,手术及麻醉与POCD,However, it is not clear whether POCD is provoked by surgery and/or anesthesia itself. It was thought that the type of anesthesia also contributed to the development of POCD. 目前尚不清楚手术和/或麻醉本身是否也引起POCD。麻醉的类型与P

13、OCD的发生也有关系。,麻醉方式与POCD,一项研究：428例年龄在60岁及以上，行非心脏手术患者，随机分为2组，局域麻醉与全麻组，术后3个月认知功能障碍发生率分别是全麻为14.3和局域麻醉为13.9 。These findings make it less likely that POCD is associated with type of anesthesia.,Prevention and prophylaxis,The knowledge on preventive strategies for POCD is limited. However, there might be sev

14、eral options to reduce the risk of the development of POCD in older adults.,Preoperatively,First of all, it is important to recognize potential risk factors preoperatively.Avoid long-acting benzodiazepines.,Intraoperatively,It might be helpful to use anesthetics that have a low metabolic rate and ra

15、pid pharmacokinetics.Furthermore, a shorter and less invasive surgical procedure is associated with a lower rate of POCD. In cardiothoracic patients, slow rewarming and prolonged mild hypothermia may contribute to the prevention of the development of POCD after extracorporal circulation.,术中应用麻醉剂是有益处

16、的，使机体处于一种低的代谢率及高的药物代谢动力学。较短的微创外科手术与POCD的发生率降低有关。 在心胸外科患者中，体外循环后，缓慢复温并持续亚低温治疗可能有助于预防POCD的发展。,Postoperatively,Adequate pain treatment reduces the incidence of POCD.Further measures include maintaining a “normal” daynight rhythm, and maintaining the homeostasis by avoiding too long fasting before and a

17、fter the procedure.Frequent visits by family and friends while the patient is still in the hospital and early discharge of patients to their own home environment also lead to a reduced incidence of POCD,Conclusion,POCD是一个主要见于大手术术后，其严重影响病人的术后结果。老年人发生POCD的风险增加，因此老人科医生，外科医生，麻醉师要了解POCD的诊断，风险因素，以及可能的预防和治疗的方法。由于POCD可能长期存在，以及越来越多的老年人接受手术，我们应作出更多努力，以获得更多关于POCD的病理生理机制。,Thank you !,