老年患者术前睡眠障碍与术后神经认知恢复延迟的相关性

Correlation between preoperative sleep disorders and postoperative delayed neurocognitive recovery in elderly patients

目的:围手术期神经认知紊乱(perioperative neurocognitive disorders,PND)是影响老年人术后恢复的重要因素之一,而睡眠障碍也是老年人常合并的疾病之一。既往研究表明术后睡眠质量可能是影响术后认知功能的因素,但鲜有术前睡眠障碍与术后神经认知功能紊乱之间的关系方面的研究。本研究旨在探讨老年患者术前睡眠障碍与术后神经认知恢复延迟的关系,以期为提高和改善患者的预后和生存质量提供参考。方法:本研究为前瞻性队列研究,连续选取2019年10月至2020年1月就诊于中南大学湘雅医院并拟行择期非心脏手术的老年(年龄≥65岁)患者,于手术前1 d应用简易精神状态检查量表(Mini-mental State Examination,MMSE)和蒙特利尔认知功能评估量表(Montreal Cognitive Assessment Scale,MoCA)评价患者的基线认知情况,剔除术前MMSE评分低于24的患者。采用匹兹堡睡眠质量指数(Pittsburgh Sleep Quality Index,PSQI)量表评估患者,并根据评分将患者分为睡眠障碍组和无睡眠障碍组。收集患者一般资料,记录患者术中资料如手术时长、麻醉时长、手术部位、术中液体输入量、术中血制品输入量、术中出血量和药物使用情况等。术后连续5 d,使用数字评估量表(Numerical Rating Scale,NRS)对前晚的睡眠情况和当天的疼痛情况进行评估,记录为睡眠NRS评分和疼痛NRS评分;使用ICU意识模糊评估法(Confusion Assessment Method for ICU,CAM‐ICU)量表、谵妄评定法(Confusion Assessment Method,CAM)量表评估是否发生谵妄。术后第7天使用MMSE和MoCA评估患者认知功能。收集并比较患者术后并发症发生情况、死亡人数、无计划入ICU人数、无计划二次手术人数等。行术后神经认知恢复延迟相关影响因素的单因素和多因素分析。结果:共收集患者105名,其中睡眠障碍组32例和无睡眠障碍组73例。2组患者的年龄、性别、体重指数、手术部位等一般资料差异均无统计学意义(均P>0.05)。2组患者手术时长、术中出血量、术后5 d内发生谵妄的人数和术后5 d睡眠NRS评分等差异均无统计学意义(均P>0.05)。睡眠障碍组术后非计划二次手术发生率明显高于无睡眠障碍组(P=0.002)。睡眠障碍组术后第1天疼痛NRS评分明显高于无睡眠障碍组(P=0.045)。睡眠障碍组术后感染发生率明显高于无睡眠障碍组(P=0.020)。共有20例(19%)患者发生术后神经认知恢复延迟,其中睡眠障碍组有11例(34.4%),无睡眠障碍组有9例(12.3%),睡眠障碍组发生率明显高于无睡眠障碍组(P=0.008)。控制混杂因素后,术前睡眠障碍仍与术后神经认知恢复延迟的发生独立相关(OR=3.330,95%CI:1.063~10.431,P=0.039)。结论:术前睡眠障碍可增加老年患者术后神经认知恢复延迟发生的风险,关注并积极处理术前睡眠障碍可改善老年患者围手术期神经认知功能。

Objective:Perioperative neurocognitive disorders(PND)is one of the important factors affecting the recovery of the elderly after surgery,and sleep disorders are also one of the common diseases of the elderly.Previous studies have shown that the quality of postoperative sleep may be factor affecting postoperative cognitive function,but there are few studies on the relationship between preoperative sleep disorders and postoperative cognitive dysfunction.This study aims to explore the relationship between preoperative sleep disorders and postoperative delayed neurocognitive recovery in elderly patients,and provide references for improving the prognosis and quality of life of patients.Methods:This study was porformed as a prospective cohort study.Elderly patients(age≥65 years old)underwent elective non-cardiac surgery at Xiangya Hospital of Central South University from October 2019 to January 2020 were selected and interviewed 1 day before the operation.The Mini-Mental State Examination(MMSE)and Montreal Cognitive Assessment Scale(MoCA)were used to assess the patient's baseline cognitive status.Patients with preoperative MMSE scores of less than 24 points were excluded.For patients meeting the criteria of inclusion,Pittsburgh Sleep Quality Index(PSQI)scale was used to evaluate the patients,and the patients were divided into a sleep disorder group and a non sleep disorder group according to the score.General data of patients were collected and intraoperative data were recorded,such as duration of surgery,anesthetic time,surgical site,intraoperative fluid input,intraoperative blood product input,intraoperative blood loss and drug use.On consecutive 5 days after surgery,Numerical Rating Scale(NRS)was used to evaluate the sleep of the previous night and the pain of the day,which were recorded as sleep NRS score and pain NRS score;Confusion Assessment Method for ICU(CAM-ICU)scale and Confusion Assessment Method(CAM)scale were used to assess the occurrence of delirium.On the 7th day after the operation,the MMSE and MoCA scales were used to evaluate cognitive function of patients.We compared the incidence of postoperative complications,the number of deaths,the number of unplanned ICU patients,the number of unplanned secondary operations,etc between the 2 groups.The baseline and prognosis of the 2 groups of patients were analyzed by univariate and multivariate logistics to analyze their correlation.Results:A total of 105 patients were collected in this study,including 32 patients in the sleep disorder group and 73 patients in the non-sleep disorder group.The general information of the 2 groups,such as age,gender,body mass index,and surgery site,were not statistically significant(all P>0.05).There was no statistically significant difference in the operation time,intraoperative bleeding,the number of delirium,and sleep NRS score at 5 days after operation between the 2 groups(all P>0.05).The incidence of unplanned second surgery after surgery and the NRS pain score on the first day in the sleep disorder group were significantly higher than those in the non-sleep disorder group(P=0.002,P=0.045,respectively).A total of 20 patients(19%)in the 2 groups had postoperative delayed neurocognitive recovery on the 7th day after surgery.Among them,11 patients(34.4%)in the sleep disorder group,9 patients(12.3%)in the non-sleep disorder group.The incidence of delayed neurocognitive recovery in the sleep disorder group was significantly higher than that in the non-sleep disorder group(P=0.008).The incidence of postoperative infection in the sleep disorder group was also higher than that in the non-sleep disorder group(P=0.020).After controlling for the confounding factors,preoperative sleep disorders were still independently associated with postoperative delayed neurocognitive recovery(OR=3.330,95%CI 1.063−10.431,P=0.039).Conclusion:Preoperative sleep disorders can increase the risk of delayed neurocognitive function recovery in elderly patients.Active treatment of preoperative sleep disorders may improve perioperative neurocognitive function in elderly patients.