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Hathaichanok Suesat, M.D.*, Varalak Srinonprasert, M.D.**, ***, Panita Limpawattana, M.D.****, Salinee
Nakyos, M.D.*****, Jiraporn Poontananggul, M.D.*, Chalita Jiraphorncharas, B.S.***, Wiraphon Manatarinat,
M.D.******, anachai Noomprom, B.S.******,
Arunotai Siriussawakul, M.D.*, ***
*Department of Anesthesiology, **Division of Geriatric Medicine, Department of Medicine, ***Siriraj Integrated Perioperative Geriatric Excellent
Research Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, ailand, ****Division of Geriatric Medicine, Department
of Internal Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, ailand, *****Division of Anesthesiology, Buddhachinaraj
Hospital, Phitsanulok 65000, ailand,******Siriraj Center of Telemedicine (SiTEL), Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok
10700, ailand
Detection of Postoperative Cognitive Dysfunction by
Telemedicine Among Octogenarian Patients Who
Underwent Minor Elective Surgery; Prospective
Cohort Study
ABSTRACT
Objective: Postoperative cognitive dysfunction (POCD) is associated with permanent disability, increased mortality,
and diminished quality of life. e incidence of acute POCD among geriatric patients who have undergone minor
surgery is uncertain because they are typically discharged before acute POCD is detected. Owing to the ecient
postoperative care that can be provided, telemedicine is an attractive tool to investigate POCD. e primary
objective of our research was to explore the incidence of acute POCD, while its secondary objective was to describe
the consequences of POCD on functional recovery and quality of life.
Materials and Methods: is prospective cohort study enrolled patients aged ≥ 80 years and scheduled for
minor elective surgery. During pre-anesthetic visits, we installed a telecommunications program on the patients’
smartphones. Assessments of cognitive and other functions were performed preoperatively and 1 week postoperatively
via telemedicine.
Results: Forty octogenarian patients undergoing minor surgery were included in the nal analysis. e acute-
POCD incidence was 10% (95% CI 4.79-18.39). Recall memory was the main cognitive domain impaired aer the
procedures. Nevertheless, there were no signicant dierences in the functional recovery and quality of life of the
POCD and non-POCD patients.
Conclusion: e acute-POCD patients demonstrated minor symptoms that were unrelated to delayed postoperative
functional recovery or decreased quality of life.
Keywords: Anesthesia; geriatrics; postoperative cognitive dysfunction; RUDAS-ai; telemedicine. (Siriraj Med J
2022; 74: 126-133)
Corresponding author: Arunotai Siriussawakul
E-mail: arunotai.sir@mahidol.ac.th
Received 12 December 2021 Revised 9 January 2022 Accepted 13 January 2022
ORCID ID: https://orcid.org/0000-0003-0848-6546
http://dx.doi.org/10.33192/Smj.2022.16
Suesat et al.
All material is licensed under terms of
the Creative Commons Attribution 4.0
International (CC-BY-NC-ND 4.0)
license unless otherwise stated.
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Original Article
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INTRODUCTION
Multiple comorbid conditions are typical in the
elderly, resulting in an increased possibility of surgical
intervention and anesthesia.
1
Postoperative cognitive
dysfunction (POCD), defined as an impairment of
cognitive function arising aer surgery, frequently occurs
among elderly patients.
2
e systemic stress response
arising during surgical procedures includes changes
in the brain function and is involved in a decline in
cognitive function.
3
Factors that elevate the risk of POCD
include increasing age, pre-existing cerebrovascular and
cardiovascular disorders, a history of alcohol abuse, and
a low educational level.
4
Perioperative hypoxemia and
hypotension, postoperative infection, and respiratory
complications are some of the recognized risk factors
for POCD.
5
POCD is associated with poorer recovery,
an increased risk of permanent disability, and the need
to utilize social nancial assistance.
4,6
POCD can be divided into acute, intermediate, and
long-term changes. “Acute POCD” is used to describe
cognitive declines detected within 1 week of surgery,
“intermediate POCD” for changes occurring within 3
months, and “long-term POCD” for declines persisting
up to 1-2 years following surgery. However, the exact
signicance of detecting POCD at these various time
points is unclear.
7
POCD was found to be present in
25.8% of patients 1 week aer non-cardiac surgery and
in 9.9% aer 3 months.
5
Other research on patients aged
≥ 60 years who had undergone minor surgery established
that their POCD incidence was 6.8% at 1 week and 6.6%
at 3 months.
8
e symptoms of acute POCD may be subtle and might
be dicult to detect among geriatric patients who have
undergone minor surgery. Patients are oen discharged
before any symptoms occur. Neuropsychological testing is
required to detect POCD by comparing preoperative and
postoperative scores.
4
e Rowland Universal Dementia
Assessment Scale (RUDAS) is a short, cognitive-screening
instrument designed to minimize the eects of cultural
learning and language diversity on the assessment of
baseline cognitive performance. e ai version of
RUDAS can be utilized for assessments conducted via
telemedicine. Telemedicine facilitates the post-discharge
monitoring of remotely delivered health care in a cost- and
time-saving manner.
9,10
e primary objective of this study
was to establish the incidence of acute POCD detected
via telemedicine among octogenarian patients who had
undergone minor surgery. e secondary objective was to
describe the consequences of POCD on their functional
recovery and quality of life.
MATERIALS AND METHODS
Study design and participants
e study was approved by the Siriraj Institutional
Review Board, Faculty of Medicine Siriraj Hospital,
Mahidol University, Bangkok, ailand (protocol approval
number Si. 168/2018) and was registered in the ai
Clinical Trials Registry (TCTR) under study number
TCTR20201216001 date registered on December 16, 2020.
Retrospectively registered. Written informed consent
was obtained from all study participants. A prospective
study was conducted at a large university-based national
tertiary referral center during the July 2018 to April 2019
study period. e inclusion criteria were patients aged
≥ 80 years who were scheduled for minor elective surgery.
Such surgery had an expected blood loss of < 500 ml,
no signicant uid shi, and no need for complex post-
operative care typically done on an ambulatory basis
(breast surgery without reconstruction; laparoscopic
cholecystectomy; hernia repair; most cutaneous, supercial,
so tissue excision; and endoscopic procedures such as
ERCP, bladder, and ureteric surgery).
11
Patients or their
caregivers needed to use smartphone support provided by
way of the “Polycom RealPresence Mobile” application.
Patients were excluded if they had factors that might
aect the execution of remote cognitive assessments,
such as an inability to understand the ai language, a
severe visual or auditory dysfunction, an unstable mental
status, or being bedridden. Patients reluctant to complete
the preoperative and postoperative RUDAS-ai test
were also excluded. e study protocol followed the
guidelines of the Declaration of Helsinki and all of its
later amendments.
e day before surgery, a sta member installed the
RealPresence Mobile application on the smartphones of
the patients or their primary caregivers, who were then
trained in its usage. e caregivers helped the patients
to establish the connection. However, they did not have
any active role during the interview or examination.
e mobile application enabled high-quality audio and
video communications to be had during preoperative
and postoperative assessments. Audio-visual data were
shared and transferred via a real-time video stream over
a 3G or 4G mobile phone network, with the intermediary
Internet Service Provider providing the soware interface
between the applications held by the hospital-based
physicians and the patients. Fig 1 illustrates the broad
process of collecting data for telemedicine purposes using
a technological network. e tests for each patient were
performed in about 30 minutes. ey were conducted
by a psychologist who was trained to communicate
with patients by oral and visual questioning based on a
questionnaire.
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128
Assessments
e RUDAS-ai version was applied to assess
cognitive functions preoperatively. The 6 cognitive
domains that RUDAS assesses are memory, praxis,
language, judgment, drawing, and body orientation.
12
e maximum total score is 30. In elderly patients with
a pre-elementary education level, preoperative cognitive
impairment was suspected if the total score was ≤ 23 (AUC
= 0.79; sensitivity and specicity of 71.43% and 76.92,
respectively), while in the case of elderly patients with a
post-elementary education, a score of ≤ 24 (AUC = 0.8,
sensitivity and specicity of 77% and 70%, respectively)
was considered the threshold. e RUDAS-ai can be
an eective alternative test and can be utilized instead
of the Mini-Mental State Examination (MMSE) for
dementia screening.
13
e present study therefore used
the RUDAS-ai to detect POCD. Acute POCD, detected
within 1 week post-operatively, was diagnosed if a score
had decreased by ≥ 3 compared with its pre-operative
level.
14,15
Several other tests were carried out to comprehensively
assess potentially aected aspects. e Barthel Activities of
Daily Living index was used to measure activity limitations
in the domains of personal care and mobility.
16
e
5-level EQ-5D questionnaire was administered to assess
quality of life.
17
Montgomery–Asberg Depression Rating
Scale testing was conducted to establish the severity of
depressive symptoms.
18
Finally, a numeric rating scale
was utilized to evaluate postoperative pain levels, while a
verbal rating scale was employed to identify the degrees
of postoperative nausea and vomiting.
Statistical analysis
e sample size calculation was based on a study
by Canet et al., which found a POCD incidence of 6.8%.
8
erefore, 43 patients were needed for the rare-event analysis
in this study. (nQuery Advisor version 7.0; Statistical
Solutions Ltd., Cork, Ireland).
19
Once an estimated 10%
loss to follow-up was added, the number of participants
required was determined to be 48.
e demographic data and clinical variables were
summarized using descriptive statistics. e continuous
data were reported as means and standard deviations, or
as medians with minima and maxima, as appropriate.
e categorical data were reported as frequencies and
percentages. e statistical analyses were calculated
using SPSS Statistics for Windows (version 18; SPSS Inc.,
Chicago, Ill., USA). A p-value of < 0.05 was considered
statistically signicant.
RESULTS
Fiy-six octogenarian patients were recruited for the
study (Fig 2). Of those, sixteen (28%) were subsequently
withdrawn due to surgery postponement, loss to follow-up,
Fig 1. e technological network of data collection with telemedicine
in health care service.
Suesat et al.
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Original Article
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or incomplete postoperative data collection resulting from
patient inconvenience or technical issues (application
errors and internet-signal problems). e data relating
to 40 patients were therefore included in the final
analysis. e number of patients needed for the study was
re-calculated, based on the actual probability of event (π)
with a 95% condence interval (CI), to conrm that a
sample size of 30 cases was adequate for the achievement
of the primary objective.
e characteristics of the octogenarian patients
who underwent minor elective surgery and anesthetic
management are detailed in Table 1. e mean preoperative
RUDAS score, Barthel Index score, EQ-5D-5L score,
and MARDS score were 23.40, 17.38, 0.860, and 2.45,
respectively. Four octogenarian patients were diagnosed
with acute POCD during postoperative Days 5-9, giving
an incidence of acute POCD of 10% (95% CI 4.8-18.4).
e characteristics of those patients are summarized in
Table 2. All four had graduated from primary school,
and hypertension was one of their coexisting diseases.
Impairment in recall memory was found with each
POCD patient. One patient received benzodiazepine to
achieve adequate sedation before surgery. Two patients
experienced intraoperative adverse events (bradycardia
or hypotension) requiring fluid resuscitation and a
vasopressor.
ere were no dierences in the functional declines,
decreases in the quality of life, or levels of depression
of the POCD and non-POCD patients (Table 3). About
3 days aer surgery, the incidence of POCD patients
who had experienced mild-to-moderate pain was 7.5%
(95% CI 3.45-15.76). e median (range) pain score for
the numeric rating scale was 0 (0, 6). Only one of the
40 octogenarian patients had a mild severity of nausea
and vomiting, occurring on the rst day aer anesthesia;
consequently, the overall incidence of postoperative
nausea and vomiting was 2.5% (95% CI 0.61-8.76).
DISCUSSION
e incidence of acute POCD in this study was 10%.
is was higher than the gure reported by a previous
study, which revealed that the POCD incidence among
patients aged ≥ 60 years and undergoing minor surgery
was 6.8% (95% CI 4.3–10.1).
8
Increasing age signicantly
elevates the incidence of POCD because, relative to
younger age groups, individuals with advanced age more
frequently have physical and mental frailty as well as a
decreased ability to cope with stresses, such as anesthesia
and surgery.
2
Yon et al, reported that anesthesia-induced
apoptotic neuro-degeneration might also be a potential
pathway mediating the development of POCD in the
older brain.
20
Glumac et al. showed that preoperative
dexamethasone administration may ameliorate the
incidence of early POCD aer cardiac surgery. is
may be because the inammatory response to surgical
procedure is a key factor in the development of POCD.
21
All 4 POCD patients had impaired recall memory
performance. A deterioration of the memory functions
is one of the most consistently reported complaints by
the elderly.
22
Work by Philp et al. demonstrated that
the associations between thalamic structure, integrity,
and higher-order cognitive processes-including the
Fig 2. Flowchart of study design.
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130
TABLE 1. Patient characteristics, type of surgical procedures, and anesthetic management.
Variables n=40
Age(years) 84.20±3.6
Gender
Female 20
Male 20
Education levels
Pre-elementary 29(72.5)
Post-elementary 11(27.5)
Monthly income (Thai baht)
≤20,000 12(30.0)
>20,000 28(70.0)
Marital Status
Married 17(42.5)
Widowed 23(57.5)
Type of surgery
Urologicalendoscopicsurgery 20(50)
Laparoscopic surgery 7 (17.5)
Breast surgery 4 (10.0)
Endoscopic retrograde cholangiopancreatography 4 (10.0)
Wound debridement 3 (7.5)
Anesthetic technique
Generalanesthesia 23(57.5)
Spinalanesthesia 11(27.5)
Deep sedation 6 (15.0)
Preoperative Scores
TheRowlandUniversalDementiaAssessmentScale 23.40±5.00
The Barthel Activities of Daily Living index 17.38 ± 3.41
The 5-level EQ-5D 0.860 ± 0.188
TheMontgomery–AsbergDepressionRatingScale 2.45±3.60
Intraoperative benzodiazepine administration 4 (10.0)
Intraoperative adverse events
Hypotension 19 (47.5)
Bradycardia 2(5.0)
Hypertension 2(5.0)
Values expressed as the mean ± SD or n (%).
Suesat et al.
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component processes of memory and the executive
functions of attention and information processing-
typically decline with age.
23
erefore, reductions in the
functional connectivity to the thalamus may contribute
to age-related cognitive decline.
24
is may explain why
most of the cognitive-domain eects in our study were
related to recall memory.
POCD is associated with functional dependence and a
poor quality of life.
21,25
Previous research has demonstrated
that even the early stages of cognitive impairment adversely
aect the quality of life.
26
In contrast, our research found
that there was no signicant development of functional
dependence or lowering of the quality of life of the
acute-POCD patients. is suggests that minor elective
surgery, ambulatory surgery, and anesthesia are quite
suitable for octogenarian patients. Depression is also one
of the most common illnesses in the elderly population.
27
Steinmetz et al. found that the occurrence of depression
was not associated with the incidence of POCD at 1
week.
28
Likewise, we found that there was no signicant
development of depression among the POCD patients.
Improvements to the population’s health literacy
has the potential to allow individuals to access health
services, to understand basic health-related information,
TABLE 2. Characteristics of the POCD patients.
Cognitive domain
Case
Age Gender Education Coexisting BDZ Operation Anesthetic Intraoperative impairments
no. diseases technique
adverse events
Recall Drawing
Language
memory
1. 80 Male Primary HT,DLP, No Urological SA Bradycardia √ √ √
school DM endoscopy
2. 82 Male Primary HT,DLP, No Urological GA No √ √
school CVA endoscopy
3. 83 Female Primary HT, DM No
Debridement
GA Hypotension √ √
school
4. 85 Female Primary HT,IHD, Yes ERCP Deep No √ √
school DLP, CVA sedation
Abbreviations: BDZ: Benzodiazepine, CVA: cerebrovascular accident, DLP: dyslipidemia, DM: diabetic mellitus, ERCP: endoscopic
retrograde cholangiopancreatography, GA: general anesthesia, HT: hypertension, IHD: ischemic heart disease, SA: spinal anesthesia
TABLE 3. Comparison of the postoperative functional recovery, depression, and quality of life of the POCD and
non-POCD patients.
Variables
POCD Non-POCD
(n=4) (n=36)
p-value
Functionaldecline 2(16.7) 10(83.3) 0.35
Depression 1 (6.7) 14 (93.3) 0.58
Decreasedqualityoflife 2(13.3) 13(86.7) 0.58
Values expressed as the n (%).
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to communicate their health statuses well enough, and
to make appropriate health decisions.
29
In other words,
adequate health literacy is key to patients’ abilities to
maintain their health, achieve behavioral change, and
eectively utilize medical services.
30
eHealth requires
the use of everyday technology, such as telephones,
computers, and services available through the Internet;
unfortunately, this can prove to be very challenging for
elderly patients.
31
Our study found that many of the
octogenarian patients had limited experience with new
technological devices, and their eHealth literacy skills
were low. e assistance of their caregivers was therefore
vital in allowing them to communicate eectively via the
application. It follows that the provision of basic training
in communications technology and the use of a less
complex eHealth application are needed to signicantly
improve the eHealth literacy of the older population.
ere were several limitations of our study. Firstly, the
anesthetic techniques and surgical procedures employed
were varied. Although all of the procedures were categorized
as minor surgery, further research should be considered
to assess the impact of technique variations on POCD,
such as the use of moderate sedation, deep sedation,
and general anesthesia. Secondly, data collection was
interrupted on occasion by technological hindrances,
such as internet-signal loss and the application not
being suciently user-friendly for the elderly. Sixteen
participants were therefore terminated from our study
due to their inability to complete the postoperative
cognitive tests. Lastly, the sample size was too small to
identify the risk factors for acute POCD in the elderly
ai population. Future studies are recommended to
establish those risk factors and to discover means of
preventing POCD onset.
In summary, the incidence of early POCD aer minor
surgery in octogenarian ai patients was higher than the
gure reported by previous research, most probably due
to the present study focusing on a much older population.
e acute POCD revealed by the current work was not
related to a delayed postoperative functional recovery
or a poor quality of life. Hence, it can be concluded that
minor elective surgery and anesthesia are quite suitable
for octogenarian patients.
ACKNOWLEDGEMENTS
This study was supported by a grant from the
Faculty of Medicine Siriraj Hospital, Mahidol University,
Bangkok, ailand (IO R016131035). e funding bodies
had no role in the design of the study; the collection,
analysis, and interpretation of data; or the writing of the
manuscript. e authors acknowledge Mrs. Nipaporn
Sangarunakul, BNS, Ms. Sunit Jarungjitaree, and Ms.
Chayanan anakiattiwibun MSc, the Siriraj Integrated
Perioperative Geriatric Excellent Research Center, Faculty
of Medicine Siriraj Hospital, Mahidol University, Bangkok,
ailand, to provide support for research.
Potential conicts of interest
e authors declare that there are no conicts of interest.
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