老年患者術(shù)后認(rèn)知功能障礙-課件

老年患者術(shù)后認(rèn)知功能障礙Postoperative?

cognitive?dysfunction?

in?geriatric?patients1ppt課件Delirium,dementia,andPOCDIncidenceanddiagnosisPotentialmechanismsofPOCDRiskfactorsPreventionandprophylaxisConclusion2ppt課件Postoperativecognitivedysfunction(POCD)isfrequentlyseenaftersurgicalprocedures.POCDisaseriouscomplicationandischaracterizedbyafunctionaldeclinewhichmaypersistformonths.3ppt課件術(shù)后認(rèn)知功能障礙（POCD）是外科手術(shù)術(shù)后常見(jiàn)的并發(fā)癥，其特征是持續(xù)數(shù)月的功能下降。尤其是老年患者，其生理上發(fā)生改變，對(duì)于手術(shù)，麻醉及一般住院帶來(lái)的壓力的能力減弱，而且老年患者越來(lái)越多，POCD更引起人們的關(guān)注。4ppt課件Delirium,dementia,andPOCDPOCDisoftenconfusedwithdementiaoracutepostoperativedelirium.POCD經(jīng)常與老年癡呆及急性術(shù)后譫妄相混淆。5ppt課件Postoperativedeliriumisfrequentlyseenfollowingasurgicalprocedureandhasbeendefinedasanacutechangeinmentalstatus,withinattentionandfluctuatingreducedlevelsofconsciousnessover24h.Themajorityofpostoperativedeliriumcasesoccurbetweendays1and7aftertheoperation.6ppt課件

術(shù)后譫妄是常見(jiàn)于外科手術(shù)后，已被定義為一種急性精神狀態(tài)的改變，表現(xiàn)為注意力不集中和波動(dòng)性意識(shí)水平下降超過(guò)24小時(shí)，常發(fā)生于術(shù)后1到7天。7ppt課件Dementia,incontrast,isachronic,irreversibleprogressivediseasethataffectsmostlyolderadults,oftenexistspriortosurgeryandanesthesia.Memoryimpairmentisoneofthehallmarksofdementia.8ppt課件與此相反，癡呆是一種慢性的，不可逆的漸進(jìn)性的疾病，主要影響的是老年人，往往存在于手術(shù)和麻醉前，記憶力障礙是老年癡呆癥的標(biāo)志之一。9ppt課件POCDischaracterizedbyalong-termstablecognitiveimpairment,whichisconsideredtobereversible,butmaypersistuptomonthsaftersurgery.POCDcanbedifferentiatedfrompostoperativedelirium,sincePOCDhasalongerdurationandnofluctuationsinimpairedcognitivefunctioning.10ppt課件POCD的特征在于，它是一個(gè)長(zhǎng)期穩(wěn)定的認(rèn)知功能障礙，這種認(rèn)知功能障礙被認(rèn)為是可逆的，但可能會(huì)持續(xù)到手術(shù)后幾個(gè)月。

POCD可以與術(shù)后譫妄相鑒別，是因?yàn)镻OCD持續(xù)很長(zhǎng)一段時(shí)間并且沒(méi)有認(rèn)知功能受損的波動(dòng)性。11ppt課件IncidenceanddiagnosisTheexactincidenceofPOCDisunknown.Inclinicalpractice,patientsarecurrentlyonlytestedaftersurgery,ifthereisasuspicionofPOCD.Therefore,thecurrentincidenceratesareanunderestimation.12ppt課件diagnosisPOCD的診斷主要是認(rèn)知能力測(cè)試。在過(guò)去的幾十年里，神經(jīng)心理測(cè)驗(yàn)已被用來(lái)測(cè)量病人的認(rèn)知能力。多個(gè)測(cè)試可用來(lái)評(píng)估不同領(lǐng)域的認(rèn)知功能障礙，如定向力，記憶力，執(zhí)行能力等，然而，所有的測(cè)試都有其局限性，現(xiàn)在測(cè)試評(píng)估POCD的方式還沒(méi)有達(dá)成共識(shí)。13ppt課件PotentialmechanismsofPOCDTheetiologyofPOCDisstillunknown.However,overthelastdecademultiplestudieshavebeenperformedonthistopic.POCD的病因仍然未知，然而已經(jīng)提出了幾個(gè)關(guān)于POCD發(fā)展的途徑。14ppt課件外科手術(shù)導(dǎo)致系統(tǒng)性的應(yīng)激反應(yīng)，釋放神經(jīng)內(nèi)分泌激素及炎癥因子，這些細(xì)胞因子可能使腦功能發(fā)生改變并促進(jìn)POCD的發(fā)展；POCD經(jīng)常發(fā)生在心臟手術(shù)的病人，可能與術(shù)后過(guò)度復(fù)溫有關(guān)；血清中S-100蛋白濃度的增加可促進(jìn)POCD的發(fā)展；大腦細(xì)胞凋亡是POCD的一個(gè)潛在機(jī)制。15ppt課件RiskfactorsforPOCDSurgery-related?risk?factorsCardiacsurgeryMajorandinvasivesurgeryLongoperationdurationPostoperativecomplicationsPatient-related?risk?factorsIncreasedageHistoryofalcoholabusePreviousPOCDHistoryofstrokeHigherASAclassification16ppt課件教育程度與POCDThelowereducationallevelfitswiththe“threshold”theoryforcognitivedecline:ifapatienthasalowereducationallevel,he/sheismorevulnerabletocognitivedecline.Asmalldeclinemay,therefore,resultincognitiveimpairment,whilepatientswithahighereducationallevelstillmightbeonanormalcognitivefunctionallevelevenafteracognitivedecline17ppt課件

教育程度較低，適合于認(rèn)知功能下降的“門檻”理論：如果病人有較低的教育水平，他/她更容易產(chǎn)生認(rèn)知能力下降，一個(gè)小的下降可能會(huì)導(dǎo)致認(rèn)知功能障礙，而患者具有較高的教育水平即使在認(rèn)知能力下降時(shí)，其仍然可能在一個(gè)正常的認(rèn)知功能水平。18ppt課件

OtherriskTheuseofbenzodiazepines，thedosageoffentanylanddifferentvolatileanestheticsdidnotaffecttheoccurrenceofPOCD.Hypoperfusionorhypoxiaofthebrainduetobloodloss,systemichypotension,orhypoxiahavebeenthoughttobepotentialcausesofPOCDintheperioperativeperiod.19ppt課件手術(shù)及麻醉與POCDHowever,itisnotclearwhetherPOCDisprovokedbysurgeryand/oranesthesiaitself.ItwasthoughtthatthetypeofanesthesiaalsocontributedtothedevelopmentofPOCD.

目前尚不清楚手術(shù)和/或麻醉本身是否也引起POCD。麻醉的類型與POCD的發(fā)生也有關(guān)系。20ppt課件麻醉方式與POCD一項(xiàng)研究：428例年齡在60歲及以上，行非心臟手術(shù)患者，隨機(jī)分為2組，局域麻醉與全麻組，術(shù)后3個(gè)月認(rèn)知功能障礙發(fā)生率分別是全麻為14.3％和局域麻醉為13.9％。ThesefindingsmakeitlesslikelythatPOCDisassociatedwithtypeofanesthesia.21ppt課件PreventionandprophylaxisTheknowledgeonpreventivestrategiesforPOCDislimited.However,theremightbeseveraloptionstoreducetheriskofthedevelopmentofPOCDinolderadults.22ppt課件PreoperativelyFirstofall,itisimportanttorecognizepotentialriskfactorspreoperatively.Avoidlong-actingbenzodiazepines.23ppt課件IntraoperativelyItmightbehelpfultouseanestheticsthathavealowmetabolicrateandrapidpharmacokinetics.Furthermore,ashorterandlessinvasivesurgicalprocedureisassociatedwithalowerrateofPOCD.Incardiothoracicpatients,slowrewarmingandprolongedmildhypothermiamaycontributetothepreventionofthedevelopmentofPOCDafterextracorporalcirculation.24ppt課件術(shù)中應(yīng)用麻醉劑是有益處的，使機(jī)體處于一種低的代謝率及高的藥物代謝動(dòng)力學(xué)。較短的微創(chuàng)外科手術(shù)與POCD的發(fā)生率降低有關(guān)。在心胸外科患者中，體外循環(huán)后，緩慢復(fù)溫并持續(xù)亞低溫治療可能有助于預(yù)防POCD的發(fā)展。25ppt課件PostoperativelyAdequatepaintreatmentreducestheincidenceofPOCD.Furthermeasuresincludemaintaininga“normal”day–nightrhythm,andmaintainingthehomeostasisbyavoidingtoolongfastingbeforeandaftertheprocedure.Frequentvisitsbyfamilyandfriendswhilethepatientisstillinthehospitalandearlydischargeofpatientstoth