POCD Risk, cholecystectomy

Gabrielle Morris

89yo lady with recent episode of gallstone pancreatitis

Background

  • Mild cognitive impairment, 22/30 on MOCA. Known to geriatrician. Living at home.
  • Pancreatitis – 1 x episode due to ? thiazide diuretics, 2nd episode with documented gallstones.
  • HTN, controlled
  • TIA
  • OA
  • Recurrent falls, mobilises with 4WW
  • DASI METS 3.9

Issues

  • Risk of POCD – Patient concerned about any possible cognitive decline. 

Discussion

  • Further episodes of pancreatitis may lead to cognitive or functional decline
  • Is there a less invasive operation possible (e.g some kind of stenting at ERCP). What would be the risks associated with any alternative procedures (e.g. failure, recurrence, sepsis, damage to surrounding structures etc)
  • What is her ongoing risk of gallstone pancreatitis if she does nothing
  • Is there any optimisation possible – known to geriatrician
  • ? role for melatonin in prevention of postoperative delirium
    • Studies and MAs suggest benefit however heterogeneity in study interventions and outcomes assessed limits the robustness of the results. 
    • Possibly acts through restoration of sleep-wake cycles and direct anti-inflammatory actions.
    • Nb. Most studies excluded patients with known pre-existing cognitive issues or those on psychoactive medications (likely the highest risk patients) 

Plan

  • Discuss with surgeon – update: no stent options since the stones would still have to pass through the pancrease where they may cause pancreatitis. Cannot quantify risk of further pancreatitis episodes. Recent literature suggests reasonable to conduct lap chole in extreme aged population. Ultimately, patient needs to weigh up the risks.
  • Discuss with patient – update – patient unsure of which path to take. Rpt appointment made with surgeons for further discussion.
  • If OT proceeds, for referral to acute inpatient geriatrics service to facilitate early geriatric co-management. See infographic below from the ASA Perioperative Brain Health Initiative. Available at https://www.asahq.org/brainhealthinitiative/tools/infographics