Der demenzkranke Patient – Was ist beim anästhesiologischen Management zu beachten?

Zusammenfassung

Aus der Alterung der Gesellschaft erklärt sich, dass Patienten mit demenziellen Erkrankungen dem Anästhesisten immer häufiger begegnen. Die Patienten und Angehörigen sind darüber besorgt, dass Anästhesie eine bestehende Demenz aggraviert oder eine postoperative Demenz (POD) hervorrufen kann. Von einigen üblichen volatilen Hypnotika und auch von Propofol ist im Tierversuch nachgewiesen worden, dass sie die Konzentration der mit einer Demenz verknüpften Proteine Tau und Beta-Amyloid im Liquor erhöhen. Die perioperativen Komplikationen kognitive Dysfunktion und Delir dieses speziellen Kollektivs treten vergleichsweise häufiger auf als in der Normalbevölkerung. Es scheint aus anästhesiologischer Sicht wichtig, regelhaft die Erkrankung Demenz präoperativ zu erfassen, um Narkoseführung und Monitoring intra- und postoperativ darauf abstimmen zu können. Zu dem interagieren Antidementiva wie Azetylcholinesterasehemmer und andere neurotrope Medikamente mit den routinemäßige in gesetzten Anästhetika.

Generell ist bei Menschen mit Demenz die kognitive Beeinträchtigung von Konzentration, Erinnerung, Informationsverarbeitung, Sprachverständnis und soziale Anpassungsfähigkeit anzunehmen und im perioperativen Management zu berücksichtigen. Diese Übersicht soll den gegenwärtigen Stand der wissenschaftlichen Kenntnisse zum Thema zusammentragen und ihn zu Empfehlungen zum perioperativen Management dieser Patenten entwickeln.

Abstract

The aging society challenges anaesthesiologists with a growing number of patients with dementia. These and their relatives worry about an aggravation of an already existing dementia or even the postoperative evocation of one. Common volatile anaesthetics and propofol are suspected to increase dementia – associated protein tau and amyloid-betalevels in the brain. Perioperative complications such as cognitive dysfunction and delirium occur more frequently in dementia patients. For anaesthesiologists, it seems prudent toassess the grade of dementia in the elderly to adjust anaesthesia drug doses and monitoring intra- and postoperatively. Pharmacological interactions with antidementic andneuroleptic current medications affectanaesthetic and analgesic effects.In dementia, perioperative malfunction of cognition, memory, attention, information processing, communication and social interaction abilities is of profound influence on the perioperative management.

This review mentions actual knowledge about dementia forms and symptoms in brief. Recommendations for the anaesthesia care are given in more detail.

Kernaussagen

• Bei der Prämedikation sind insbesondere die Fremd- und Medikamentenanamnese, der Demenzschweregrad, der Betreuungsstatus und die den Pflegenden bekannten Schmerzäußerungshinweise zu erheben.

• Lebenshilfen wie Hörgeräte oder Gedächtnis- und Kommunikationshilfen sollten den Patienten nicht entzogen werden. Präoperative Blutzuckerentgleisungen und Bluttransfusionen erhöhen die Delirgefahr.

• Der perioperativen Abschirmung ist aufgrund der häufig vorhandenen Angst und der vergesellschafteten Depression ein hoher Stellwert einzuräumen.

• Anästhesiologische Verfahren, die eine sichere und effektive Analgesie versprechen (kontinuierliche Regionalanästhesietechniken), und Monitoringmethoden, die zur Reduktion der gesamten Dosis an neurotropen Medikamenten beitragen (Narkosetiefenmonitoring), sollten angewandt werden.

• Demenzkranke erfahren z.T. eine erhöhte Sensibilität für Anästhestika und Neuroleptika, die eine Reduktion auf ca. ein Drittel der üblichen Dosis bedingt. Andererseits kann eine Resistenz vorliegen (z. B. auf NSAID bei der hereditären DAT).

• Die Resistenz gegen Muskelrelaxanzien hängt von der Dauer der Antidementivatherapie ab. Succinylcholin kann verlängert wirken.

• Der Analgetikabedarf von Demenzkranken ist eher erhöht.

• Die Interaktionen der perioperativ notwendigen Medikamente mit den zur Demenz- und Depressionstherapie häuslich verordneten Medikamenten sollten ebenso berücksichtigt werden wie bekannte Organminderfunktionen, die zu einer veränderten Pharmakologie führen.

• Die postoperative Schmerztherapie soll anhand spezieller Algometrie beim Dementen laut S3-Leitlinie zur Anwendung kommen.

• Bei den demenzspezifischen perioperativen Komplikationen sind postoperatives kognitives Defizit, postoperative Demenz, Delir, zentrales anticholinerges Syndrom, Serotonin-Syndrom und malignes neuroleptisches Syndrom abzuwägen.

Schlüsselwörter:

Demenztypisierung - Prämedikation des Demenzkranken - Schmerztherapie bei demenziellen Erkrankungen - Narkoseführung beim Dementen - POCD - Delir - postoperative Demenz

Key words:

dementia type - preassessment of dementia patients - pain therapy in dementedpatients - anaesthesia management for dementia - POCD - delirium - postoperative dementia

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