Evaluation of the effects of dexamethasone on the incidence of postoperative cognitive dysfunction in elderly patients undergoing general anesthesia

Introdução: Disfunção cognitiva pós-operatória (POCD) é um evento adverso multifatorial mais frequente em pessoas com idade superior a 60 anos ou doenças neurológicas e psiquiátricas. Este estudo avaliou o efeito da dexametasona sobre a incidência de POCD em idosos após cirurgia não cardíaca sob anestesia geral. Métodos: Cento e quarenta pacientes (ASA I-II, idade 60-87 anos) participaram deste estudo prospectivo, randomizado, envolvendo a administração ou não de 8 mg de dexametasona IV antes da indução anestésica para anestesia geral profunda ou superficial de acordo com o índice bispectral. Os testes neuropsicológicos foram aplicados no pré-operatório e em 3, 7, 21, 90 e 180 dias após a cirurgia e comparados com os dados normativos. Enolase específica do neurônio e S100beta foram avaliados antes e 12 horas após a indução da anestesia. A regressão linear com inferência baseada no método de equações de estimação generalizadas (GEE) foi aplicado, seguido pelo teste post-hoc de Bonferroni, considerando P 0,999), sendo que após 180 dias os pacientes com o alelo APOe4 apresentaram alteração na função executiva para a flexibilidade mental quando comparados aos pacientes sem o alelo (p 0.999), and after 180 days the patients with the APOe4 allele had alterations in Executive function for mental flexibility when compared to patients without the allele (p < 0.001). Conclusion: Dexamethasone can minimize the incidence of POCD in elderly patients undergoing non-cardiac surgery, especially when associated with superficial anesthesia. The effect of dexamethasone on S100beta e NSE serum levels might be related with some degree of neuroprotectio

The MentalPlus® Digital Game Might Be an Accessible Open Source Tool to Evaluate Cognitive Dysfunction in Heart Failure with Preserved Ejection Fraction in Hypertensive Patients: A Pilot Exploratory Study

Introduction. Cognitive dysfunction with heart failure with reduced ejection fraction (HFrEF) is well studied. However, there are few comparative studies with heart failure and preserved ejection fraction (HFpEF). Cognitive dysfunction diagnosis usually demands a long neuropsychological battery. We developed MentalPlus® digital game to overwhelm that issue. Methods. As a pilot study, we evaluated 60 patients with systemic hypertension and HFpEF. They were submitted to TICS (Telephone Interview Cognitive Status) to evaluate the general cognitive function and 25 minutes of MentalPlus® digital game evaluation. Results. The results disclosed 60 hypertensive patients. All of them presented with HFpEF. Patients presented a mean age of 56±10 years; 46% male; LVMi (g/m2) mean of 110±20; educational attainment of 9 years or more; mean income of 8 Brazilian minimum wages. The TICS results disclosed 28 ±3.7. MentalPlus® digital game evaluation disclosed preserved values for the phases I, III, IV, V, VI, and VII. Phase II, short-term memory related, was below the normals values that were assigned. This group of patients presented a normal general cognition by both evaluations, except for specific functions displayed above, disclosed by MentalPlus®. The MentalPlus® was designed to possibly evaluate specific cognitive functions separately, like attention, memory, executive function, and language, because each phase evaluates specific functions shortly. Conclusion. Hypertensive HFpEF patients presented in general a normal cognition, except for some aspects related to short-term memory. The MentalPlus® digital game, compared with TICS, presented similar general results. It is an advantage that MentalPlus® software could be used to assess cognitive function, in general and individually, and be an open tool shortly

Effects of Single Low Dose of Dexamethasone before Noncardiac and Nonneurologic Surgery and General Anesthesia on Postoperative Cognitive Dysfunction—A Phase III Double Blind, Randomized Clinical Trial

<div><p>Postoperative cognitive dysfunction (POCD) is a multifactorial adverse event most frequently in elderly patients. This study evaluated the effect of dexamethasone on POCD incidence after noncardiac and nonneurologic surgery. METHODS: One hundred and forty patients (ASA I-II; age 60–87 years) took part in a prospective phase III, double blind, randomized study involving the administration or not of 8 mg of IV dexamethasone before general anesthesia under bispectral index (BIS) between 35–45 or 46–55. Neuropsychological tests were applied preoperatively and on the 3rd, 7th, 21st, 90th and 180th days after surgery and compared with normative data. S100β was evaluated before and 12 hours after induction of anesthesia. The generalized estimating equations (GEE) method was applied, followed by the posthoc Bonferroni test considering P<0.05 as significant. RESULTS: On the 3rd postoperative day, POCD was diagnosed in 25.2% and 15.3% of patients receiving dexamethasone, BIS 35–45, and BIS 46–55 groups, respectively. Meanwhile, POCD was present in 68.2% and 27.2% of patients without dexamethasone, BIS 35–45 and BIS 46–55 groups (p<0.0001). Neuropsychological tests showed that dexamethasone associated to BIS 46–55 decreased the incidence of POCD, especially memory and executive function. The administration of dexamethasone might have prevented the postoperative increase in S100β serum levels. CONCLUSION: Dexamethasone can reduce the incidence of POCD in elderly patients undergoing surgery, especially when associated with BIS 46–55. The effect of dexamethasone on S100β might be related with some degree of neuroprotection.</p><p><b><i>Trial Registration</i>:</b><a href="http://www.clinicaltrials.gov/" target="_blank">www.clinicaltrials.gov</a><a href="https://clinicaltrials.gov/ct2/show/NCT01332812?term=NCT01332812&rank=1" target="_blank">NCT01332812</a></p></div

Study Fluxogram.

<p>MMSE: Mini-Mental State Examination; ITT: Intention to treat.</p

Intraoperative data.

<p>Data are mean ± SD; BIS: bispectral index; *<b><i>p</i>-value</b> for the Generalized Estimating Equations (GEE).</p

S100β serum level.

<p>BIS: bispectral index; Mean ± SD: Mean ± standard deviation. <i>* = p</i><0.05 as compared to baseline biomarkers S100β level.</p

Pre and postoperative results of the specific test: for global cognitive, memory, attention, executive functions, and Quality of life and depressive symptoms, compared to normative data ^a.

<p>BIS: bispectral index; POCD: postoperative cognitive disorder; TICS: Telephone interview for cognitive status; RAVLT immediate: Rey Auditory- verbal learning test (immediate); RAVLT delay: Rey Auditory- verbal learning test (delay); TMT-A: Trail making test- A; TMT-B: Trail making test-B; SDMT: symbol digit modalities—Test; SF-36 general health: Short form health survey (general health); SF-36 Mental Health: Short form health survey (mental health); BDI: Back depression inventory. ^a Normative values. Data are mean ± SD and percentage for patients with POCD. TICS: 27±3; VLT: immediate 6.3±2.1; delay 10.2±2.5; TMT-A ≥ 55 and TMT-B ≥137; SDMT 50.1±8.1; SF-36 scale >60±10; BDI <12; Pop = Preoperative; Postoperative days = 3^rd; 7^th; 21^st; 90^th and 180^th; ^b *<i>p</i>-value for the Generalized Estimating Equations (GEE).</p