Surgery: Current Research

Postoperative Cognitive Dysfunction in Elderly Women Having Surgery for Pelvic Organ Prolapse

Divya Chauhan^{* *}Correspondence: Divya Chauhan, Department of Life Sciences, Graphic Era (Deemed to be) University, Uttarakhand, India, Email:

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Introduction

A temporary decline in cognition following surgery known as Postoperative Cognitive Dysfunction (POCD) is largely characterized by memory, focus, and information processing speed problems. It is different from dementia and delirium. Normally, POCD lasts a few days to a few months, but it has been known to last up to 7.5 years. Despite the fact that the length of POCD varies, older persons (those over 60 years) who have it are more likely to experience a delayed postoperative recovery, a larger loss of independence, higher health care expenses, and higher rates of morbidity and mortality. Because the diagnosis requires neuropsychological testing, which is not frequently done in the clinical context, health care practitioners frequently underestimate the prevalence and detrimental effects of POCD.

Surgery for Pelvic Organ Prolapse (POP) is becoming more and more popular among women over 60 years. Given the anticipated 24% expansion in the US population, the demand for treatment of pelvic floor problems, such as pelvic organ prolapse, is expected to rise by 35% between 2010 and 2030. Thus, as the number of elderly persons in the US population grows, more patients will request POP surgery during the coming decades.

After non-cardiac, elective surgery, POCD can range from 7% to 26%. One of the largest studies examining POCD following non-cardiac surgery found a 25.8% incidence at one week postoperatively and a 9.9% prevalence at three months. Given their advanced age, a known risk factor for POCD development in elective, non-cardiac surgery patient populations, and the availability of nonsurgical therapy options for many women, it is crucial to identify risk factors for POCD in the urogynecologic patient population. Understanding the risk of POCD and how it affects postoperative recovery in the urogynecologic patient population is essential since the possibility of this result may affect the choice to proceed with surgery. It is unclear how common POCD is among patients who need urogynecologic care. We sought to find out the prevalence of POCD in women 60 years of age and older two weeks following POP surgery due to the dearth of available research in this area. According to the hypothesis, the incidence rate is comparable to the 20% reported rates in populations of older patients having major elective, non-cardiac surgery.

 

Discussion

The incidence of POCD two weeks after surgery was 33.3% in this group of older women who had surgery for symptomatic pelvic organ prolapse, which was much higher than the anticipated prevalence of 20%. When compared to previous studies of men and women with age means or medians of 60+ years, the study cohort's median age of 72 years is older, suggesting that this higher incidence is likely due to this. The study's findings are consistent with those, who in their extensive prospective analysis of 425 persons aged 70 years one week after abdominal, thoracic, or orthopaedic surgery reported a 29% incidence of POCD. In a group of 333 older persons older than 60 years, a 41.4% POCD incidence one week following abdominal, thoracic, or orthopaedic surgery was described. The variety of the POCD criteria applied in published research papers is another element influencing the variation in our reported rate of POCD compared to incidence rates from other studies. A review of earlier studies on POCD shows that the statistical analytic criteria used to diagnose POCD and the types of neuropsychological tests used to evaluate cognition vary widely. In order to assure accurate evaluation and reduce the ceiling effect, a full battery of neuropsychological tests, a definition of POCD that adhered to the same standards as previous significant research, and trained neuropsychological assessors to administer the tests was used.

Although it is possible that our estimate of a 33.3% incidence of POCD is overstated, it is likely true because the test battery utilized can detect very modest cognitive losses that may ultimately affect older women's functional status, postoperative recovery, and well-being. It's likely that if we had tested 1 week after surgery rather than 2 weeks later, we could have discovered a higher rate of POCD. However, considering its clinical relevance to recovery and early independence for surgical patients following prolapse surgery, we were mainly interested in the 2-week postoperative time point. As far as we are aware, this is one of the first studies to look at POCD in this particular group of older women who had voluntary prolapse repair surgery.

Additionally, we discovered that POCD development in this cohort was associated with higher Fried Frailty index scores but not frail status, most likely as a result of the small number of women in our cohort who fit the criterion (n=9). It has been discovered that preoperative fragility is often linked to more negative outcomes and postoperative problems. There aren't many research that have specifically linked preoperative fragility to the emergence of POCD. In a prospective cohort study, 100 older persons aged 65 years or older who underwent elective spine surgery, it was discovered that 50% of the frail patients showed sustained cognitive impairment from their baseline. Notably, this study used an unique questionnaire for measuring quality of life to assess cognitive recovery. This link makes sense given that elderly, fragile people are more susceptible to organ function reductions that may affect how well they tolerate anesthesia and surgery. As a result, fragility should be taken into account while making surgical decisions as a risk factor for POCD.

Women with POCD had considerably higher baseline Geriatric Depression Scale scores than non-POCD women. Given the low absolute raw scores (score mean (SD) of 1.4(1.6) in women without POCD vs. 2.7(2.8) in women with POCD), the therapeutic significance is questionable. Both groups average GDS-SF scores fall below the threshold of greater than 5, which has been linked to moderate or severe depression symptoms. There are conflicting reports about the connection between depression and POCD in the current available research. Preoperative history of depression was not linked to POCD in a sample of patients who underwent elective, non-cardiac surgery. Outside of the surgical environment, further work has documented links between depression and cognitive impairment as well as links between depression and POCD. In this sample, POCD was not correlated with a history of clinical depression; rather, there was a statistically significant correlation between higher GDS-SF scores and POCD. Given the higher prevalence of subthreshold depression compared to severe depression among older women, this finding and consideration are significant. Both have been linked to a lower quality of life and a higher morbidity. Given that the majority of studies on POCD have identified older age as an associated or predictive factor, we expected that older age would be linked with POCD. Additionally, using inhalational anesthetics would be linked to POCD was predicted. In comparison to inhalational anesthesia, there is low-certainty evidence that propofol-based complete intravenous anesthesia may lessen Postoperative Cognitive Dysfunction (POCD). Although we acknowledge we lack the power to provide information on specific risk factors for POCD because this was an experimental goal, these factors were not linked to the development of POCD in the study group.

The limitations of the study should be taken into account when interpreting the results. First of all, there was no control group. To gauge cognitive change, we compared performance with the baseline. To enable the calculation of a Reliable Change Index (RCI), which would account for ceiling/floor effects as well as test-retest reliability, it would be ideal to include a control group, specifically with two assessments at the same interval of time (roughly four weeks) without the surgical intervention. Given the difficulties in locating women who were offered surgical prolapse repair and had time to organize two testing sessions with a four-week gap before receiving the surgical surgery, we did not include a control group in our study design. Second, despite the fact that the age range and range of prolapse procedures performed generally reflect the population of women who seek surgical intervention for prolapse, generalizability to other populations is limited by the study's predominantly white and locally based cohort (all from western Pennsylvania). Generalizability is also constrained by the exclusion of women who had prior cognitive impairment, a known risk factor for the emergence of POCD. To find new instances of cognitive impairment linked to the surgery, we nevertheless included preoperative cognitive imp- -airment as an exclusion criterion on purpose. Third, it can be thought that a 2-week postoperative assessment time point is too brief. We purposefully chose a 2-week postoperative assessment since this period best depicts when the initial anesthetic effects have subsided, patients have returned home (resuming the majority of their daily functional activities), and little to no opioid medication is being utilized. It is also the point at which the majority of safety-net services, like home health nursing or assistance, are stopped. Recommendations for standardized nomenclature and definitions used in research on perioperative neurocognitive disorders, including postoperative cognitive dysfunction with the Nomenclature Consensus Workgroup. These suggestions will aid in the interpretation of findings in this field of inquiry due to the great variety in the criteria and metrics used to characterize postoperative cognitive impairment and other perioperative neurocognitive disorders. Based on these guidelines, the term "delayed neurocognitive recovery" should be used to describe what was formerly known as POCD at a 2-week interval after surgery. Although this particular cohort was not followed for longer than two weeks following surgery, the findings are nonetheless important since these cognitive alterations may affect women's capacity to take care of themselves during the delicate postoperative recovery phase.

This study's prospective design and use of a thorough battery of neuropsychological tests given by qualified assessors were both strengths. Common cognitive tests like the 3MS or mini-cog, when used alone, are less sensitive in detecting cognitive loss as it relates to various cognitive areas. Given its influence on surgical decision-making and informed consent talks between surgeons and patients, awareness of POCD as a potential complication is crucial, particularly in the context of elective surgery performed primarily for quality-of-life objectives.

When elderly women have their pelvic organ prolapse surgically repaired, POCD is a common side effect. Our research verified that two weeks following surgery, as many as 33% of women showed sustained decline from their baseline in memory, executive function, and/or attention domains. Greater depression and frailty scores were found to be risk variables for the development of POCD in this investigation. This diagnosis and its accompanying risk factors should be known by surgeons, patients, and their families in order to guide surgical choice and postoperative recovery planning. Our findings call for further research since they have repercussions for other surgical professions that frequently operate on female patients for significant elective non-cardiac procedures. Future research should look into how long POCD lasts and how it affects postoperative recovery and functional status.