Mohammed T. Abou-Saleh

746 PRINCIPLES AND PRACTICE OF GERIATRIC PSYCHIATRYTable 137.1Randomized studies comparing the psychometric effects* of general anaesthesia (GA) and regional anaesthesia** (RA)ReferenceNumber ofpatientsAge(years)Type of surgery[anaesthesia]Timing ofpostoperativetestsMain findingsDifferencebetweenGA/RA?Long-term cognitivedeficit?19 262 >40,median69knee replacement(TKR)[Epidural vs.general anaesthesia]20 169 65–98 Cataract[GA vs. local]21 146 patients,50 controls(patients onwaiting list)60+ hip (THR) or kneereplacement[GA vs. epidural]22 64 60–86 TKR[GA vs. spinal]23 40 60–80 Transurethralresection ofprostate (TURP)[GA vs. epidural]24 105 25–86 Hysterectomy,TURP, THR/TKR25 30 50–80 THR[GA vs. spinal]26 44 60–93 TURP, pelvic floorsurgery[GA vs. spinal]27 57 65–92 Hip fracture[GA vs. epidural]28 40 >60 Hip fracture[GA vs. spinal]29 30 >60 THR[GA vs. epiduralvs. both]30 60 >65 Cataract[GA vs. local+sedation]31 60 56–84 THR[GA vs. epidural]*For full details of psychometric tests, see references 4, 37.**Regional anaesthesia includes local, spinal and epidural anaesthesia.7 days,6 months1, 14 days,3 monthsDelirium occurred in 11%.Complex changes in psychometrictests, but there was ageneral reduction at 7 days withreturn to baseline (or better) by6 months. However, TrailMaking A and B worse at 6monthsReduction in verbal recall/learning,psychomotor speed andtactile naming on day 1 only3 months No decreases on tests in patientsor controls at 3 months. Testsincluded Choice Reaction Time(which increased in GA group),object learning, digit copying,critical flicker fusion, andcognitive difficulties scale3 months Tests tended to improve at 3months (? practice effect)4, 21 days Day 4 only: reduced pairedassociate learning, visual memoryand visual recall1–7 days,3 monthsModest decrease in memory andcognitive tasks in early period.Later tests usually better thanbaseline1, 2, 7 days Spinal group had worse wordrecall/recognition on day 1, nodifferences on later days6h,1,3,5 days,1 monthAt 6 h GA group had reducedMini-Mental Status. No laterdifferences on Mini-Mental orGeriatric Mental Assessment1, 7 days 38–50% Delirium (even thoughpatients excluded if OrganicBrain Syndrome Scaleabnormal preoperatively)7 days,3 months2, 4, 7 days,3 monthsAbbreviated Mental Testimproved at 1 week (noother test was used)Assessment by psychologist.Various tests impaired for2–4 days, then recovered7 days Wechsler Memory Scale andLuria tests reduced relative tobaseline1, 3, 7,12 daysNo formal psychological tests; 7out of 31 in GA group (0 out of29 epidural group) said to havemental changes in first 7 daysNoNoNoNoNoNoYesYesNoNoNoYes (LAworse, Luriaonly)Yes5% Showed significantdeterioration at 6months, but therewere no untreatedcontrolsNoNo measurabledecrease, but 11/56GA and 10/60 RApatients thoughtconcentration andmemory werepoorerNoNoNoNot testedNoNot testedNoNoNot tested5 out of 31 GApatients reportedmental changes4–10 months aftersurgeryA key feature of the ISPOCD studies has been the use of theEuropean psychometric test battery (EUPT battery), which hasbeen designed as a sensitive and standardized research tool for thedetection of postoperative neuropsychological deficits and whichcan be administered over a 45 min period. This battery uses theMini-Mental State Examination (MMSE) as a screening test, withpatients scoring 23 or less being excluded from further testing.The remaining tests (used in ISPOCD1 and in a slightly modifiedform in ISPOCD2) comprise a Verbal Learning Test, a ConceptShifting Test, the Stroop Colour Word interference test, a LetterDigit substitution task, a four boxes test, the Broadbent CognitiveFailure Questionnaire, and a Zung Depression Score Questionnaire(the Geriatric Depression Scale being used in ISPOCD2).The definition of postoperative cognitive dysfunction (POCD) hasbeen reached by comparing changes in the normalized (Z) scoresof individual patients with age-matched controls who were notundergoing surgery, who were studied at the same time intervals.ISPOCD1 32 was particularly concerned to test the hypothesisthat hypoxaemia and/or hypotension were causative factors inPOCD. Accordingly, oxygen saturation was measured by