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KEY POINTS

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KEY POINTS

  1. Cognition represents key processes of memory, attention, perception, and problem solving that are necessary for our overall quality of life and for the completion of activities of daily living.

  2. Surgery and anesthesia are associated with postoperative delirium and cognitive dysfunction, which can be differentiated by their timecourse and clinical presentation.

  3. Cognitive assessment occurs by a number of well-validated measurements outlined in the field of neuropsychology. Assessment of cognitive functioning in the perioperative period is often less complete than normal; however, understanding what is measured by each individual test and how these values change over time is essential in understanding the implications to our patients of perioperative cognitive decline.

  4. The incidence of postoperative cognitive dysfunction varies with the sensitivity of the tests used and the timeframe for evaluation. Comparing surgical patients with appropriate nonsurgical controls gives the best idea of the relative impact of surgery and anesthesia on changes in cognition and quality of life.

  5. There is widespread agreement that postoperative cognitive dysfunction (POCD) typically lasts from weeks to months after perioperative care. It remains controversial whether POCD can last longer than 3 months, although clear evidence suggests that early postoperative delirium and POCD are each predictive of longer term cognitive decline.

  6. The etiology of POCD is complex and is associated with patient factors, including atherosclerosis and diabetes and genetic factors, as well as with procedural factors (surgery and anesthesia). The effect of specific anesthetic agents on short- and long-term cognition is controversial. It is unclear whether any specific anesthetic technique or agent is associated with better long-term cognition, although careful anesthetic dosing and titration may reduce the risk of both POCD and delirium.

  7. Determining the risks of perioperative cognitive decline enhances the probability of developing interventions to reduce cognitive decline and thus improve quality of life after surgery.

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INTRODUCTION

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Although general anesthesia and surgical manipulations are often viewed as transient stressors, emerging evidence shows that both may have longlasting effects on the brain and mind. In particular, many patients experience difficulties with thinking and memory after undergoing anesthesia and surgery. Elderly patients are at higher risk for these cognitive problems after anesthesia and surgery, likely because of reduced cognitive reserve and increased cerebral atherosclerosis. These changes in cognitive function are associated with impaired activities of daily living, which substantially reduce the quality of life in elderly patients.1

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The safety of anesthesia and surgery has progressed over several decades to the point that elderly and debilitated patients may safely undergo increasingly complex procedures with low risk of major morbidity or mortality. However, anesthesia and surgery appear to be associated with changes in cognitive functioning that outlast the effects of anesthesia or pain medications, inflammation, and the healing response. Several studies have investigated changes in cognitive functioning associated with cardiac and noncardiac surgery.2-6 Although much attention has focused on cognitive dysfunction after anesthesia and surgery, emerging evidence suggests that ...

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