jurnal

Comparison of early cognitive function and recovery afterdesflurane or sevoflurane anaesthesia in the elderly: a

double-blinded randomized controlled trial

D. Rortgen, J. Kloos, M. Fries, O. Grottke, S. Rex, R. Rossaint and M. Coburn*

Department of Anaesthesiology, University Hospital Aachen of the RWTH Aachen, Pauwelsstreet 30,

D-52072 Aachen, Germany

*Corresponding author. E-mail: [email protected]

Background. Postoperative cognitive dysfunction (POCD) is being recognized as a compli-

cation contributing to perioperative morbidity and mortality of the elderly. We hypothesized

that the use of the shorter-acting volatile anaesthetic desflurane would be associated with less

incidence of POCD when compared with sevoflurane.

Methods. Approved by the local ethical committee, 80 patients (aged 65–75 yr) were enrolled

in this randomized, double-blinded study. Patients were allocated to either the desflurane (n¼40)

or the sevoflurane (n¼40) group. The primary outcome was the cognitive Test for Attentional

Performance with its subtests Alertness, Divided Attention, Visual Scanning, Working Memory,

and Reaction Change. In addition, Paper–Pencil Tests [Well-being Test BF-S, Recall of Digit Span

(DST), Digit-Symbol-Substitution Test, Trail Making Tests A and B, and Spielberg State-Trait

Anxiety Inventory] were measured. After baseline assessment 12–24 h before operation, patients

were followed up 6–8 and 66–72 h after operation. Among other outcome parameters, emer-

gence times from anaesthesia and modified Aldrete scores were recorded.

Results. There was no difference in the incidence of POCD. However, according to the Paper–

Pencil Tests, significant improvements for the desflurane group could be detected (Well-being

Test at 6–8 h, DSTat 6–8 h, and Trail Making Test at 66–72 h). Emergence was significantly faster

in the desflurane group for ‘time to open eyes’ and ‘time to extubation’.

Conclusions. The total incidence of POCD showed no differences between the desflurane and

the sevoflurane groups. However, the tests Well-being scale, DST, and Trail Making Test, emer-

gence times, and patients’ satisfaction were in favour of desflurane.

Br J Anaesth 2010; 104: 167–74

Keywords: anaesthesia, geriatric; anaesthetics volatile, desflurane; anaesthetics volatile,

sevoflurane; recovery, cognitive; recovery, postoperative

Accepted for publication: November 23, 2009

The World Population Data Sheet of the year 2007

reports that 16% of the population in the industrial states

is older than 65 yr.1 With increasing life expectancy,

more and more patients aged 65 or older will receive

general anaesthesia. Patients older than 60 yr are particu-

larly affected for postoperative cognitive dysfunction

(POCD) (26–41%).2 3 Alarmingly, patients experiencing

POCD are at an increased risk of death in the first year

after surgery.3 In conclusion, considering the increasing

numbers of the aged, POCD is a problem of growing

importance.

Desflurane and sevoflurane are widely used volatile

anaesthetics. Both are characterized with a low blood–gas

partition coefficient [desflurane (0.42) and sevoflurane

(0.69)]. Concerning emergence times, desflurane has been

associated with shorter emergence times when compared

with sevoflurane, but early recovery of cognitive function

seems to be similar.4 In this study, we used Paper–Pencil

Tests and complemented them with the cognitive Test for

Attentional Performance (TAP) with its subtests Alertness,

Divided Attention, Visual Scanning, Working Memory,

and Reaction Change.5 6

# The Author [2009]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.

For Permissions, please email: [email protected]

British Journal of Anaesthesia 104 (2): 167–74 (2010)

doi:10.1093/bja/aep369 Advance Access publication December 30, 2009

by guest on January 16, 2016http://bja.oxfordjournals.org/

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The aim of this study was to compare early cognitive

function in the elderly after general anaesthesia with either

desflurane or sevoflurane using the computerized and

established TAP as the primary outcome. We hypothesized

that the use of the less soluble and faster-acting volatile

anaesthetic desflurane would be associated with less inci-

dence of POCD when compared with sevoflurane.

Methods

The primary outcome parameter was the cognitive function

assessed with the computerized TAP (Version 1.7; Psytest,

2002), as reported previously.5 6 Of note, in this study, the

TAP was performed using an augmented set of subtests.

This was implemented to cover a broad range of cognitive

domains, including Alertness, Divided Attention, Visual

Scanning, Working Memory, and Reaction Change. In

addition to the TAP, a selection of ‘classical’ cognitive tests

is assessed as secondary outcome parameters, in the course

called Paper–Pencil Tests, according to the way of assess-

ment. This selection includes the Digit-Symbol-Substitution

Test (DSST), Recall of Digit Span (DST), and the Trail

Making Tests A and B.7 8 In addition, the short form of the

Spielberger State-Trait Anxiety Inventory (STAI) and the

Well-being Test BF-S are integrated in the Paper–Pencil

Tests to measure anxiety and depression in this study.9 10

POCD was defined as being a 20% decline in 20% of both

the Paper–Pencil Tests and the TAP.11 The TAP assessment

was completed by the study subjects in about 45 min.

Eighty patients, aged 65–75 yr, ASA I–III, were

enrolled in this clinical trial. The trial was approved by the

local ethics committee. Randomization was computer-

generated and allocation concealment was ensured by

enclosing assignments in sealed, sequentially numbered

envelopes. The anaesthetist could not be blinded owing to

the different administration methods of the anaesthetics;

however, both study investigators and patients were

blinded to group assignment (double-blinded observation).

The baseline measurements of the TAP and of the

Paper–Pencil Tests were performed 12–24 h preoperative,

after obtaining written informed consent. The study sub-

jects were visited by the investigator and were instructed

in a standard way on how to use the test battery (TAP) and

the Paper–Pencil Tests. To prevent distraction from clini-

cal routine and to guarantee a most identical setting, the

room-sharing patients were asked to leave the room and

all electronic devices such as telephone and TV were

switched off. The 6–8 and 66–72 h postoperative testing

were assessed in the same way for each patient. At all test

time points, the study subjects first performed the TAP fol-

lowed by the Paper–Pencil Tests.

For the secondary outcome parameters, the emergence

times from anaesthesia were recorded, including the time

of tracheal extubation. At a 20 s interval, starting from the

time of discontinuation of anaesthetic administration, a

blinded investigator asked each patient to open his or her

eyes, squeeze the investigator’s hand, and state time

(actual day) and spatial orientation until correct answers

were given. Every patient was discharged to the post-

anaesthetic care unit (PACU) for immediate recovery as

soon as they were able to be transported safely to the

PACU. At arrival, 5, 10, 15, 30, 45, 60 min, and at dis-

charge, the modified Aldrete scores with a 10-point scale

were recorded in the PACU.12 The patients were asked for

nausea and pain at the same time intervals. Additionally,

vigilance, well-being, and energy were recorded at the

same time. Therefore, an independent investigator assessed

the patients’ vigilance; well-being and energy were evalu-

ated by spontaneous patients’ statements. Vigilance was

rated as awake, tired, or sleeping. Well-being was classi-

fied as excellent, good, fair, and poor. Energy was divided

into normal, fair, and poor.

Further, the patients were questioned 6–8 h postopera-

tive for patients’ self-evaluation of the anaesthesia

procedure, assessed by marks from one to six (excellent–

unsatisfactory). Additionally, the patients were asked

whether they would choose the same anaesthesia if necess-

ary for further operations.

The patients underwent elective surgery in traumatol-

ogy, ear, nose, and throat surgery, gynaecology, urology,

or neurosurgery. Of note, neurosurgical interventions were

limited to operations on the spine. Chronic alcohol or drug

abuse, disturbed renal or liver function, diabetes mellitus,

disabling neuropsychiatric disorders, history of stroke, car-

diopulmonary resuscitation, or brain trauma in the last 12

months, increased intracranial pressure, anaphylactic reac-

tion to anaesthetics, emergency operations, history of myo-

cardial infarction, adrenal insufficiency, congestive heart

failure, and lack of cooperation or legal incapacity were

excluded for eligibility. Duration of anaesthesia was

planned for at least 60 and up to 180 min. Standard moni-

toring included three-lead ECG, pulse oximetry, non-

invasive arterial pressure measurements, temperature (AS/

3 monitor, GE-Datex Ohmeda, Helsinki, Finland), bispec-

tral index monitoring (BIS model A 2000w, Software

Version 2.21, Aspect Medical Systems, Boston, MA,

USA), and the measurement of end-tidal carbon dioxide,

oxygen, and anaesthetic gas concentrations. All mentioned

parameters were recorded at fixed intervals of 5 min. For

induction of anaesthesia, patients were preoxygenated with

oxygen 100% for 3 min followed by a slow i.v. injection

of propofol (2 mg kg21) and simultaneously given remi-

fentanil at 0.5 mg kg21 over 60 s. Rocuronium in a dosage

of 0.6 mg kg21 was used to facilitate tracheal intubation.

Depth of anaesthesia was controlled by adjusting desflur-

ane or sevoflurane to age-adapted equipotent minimum

alveolar concentration (MAC) between 4.2 and 4.5 vol%

(desflurane) or 1.1 and 1.4 vol% (sevoflurane) in oxygen

30%13 (Cato Draeger, Lubeck, Germany) and administer-

ing remifentanil at a base rate of 0.15 mg kg21 min21.

During surgery, remifentanil was titrated due to clinical

needs. On the basis of the patient’s haemodynamic

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(systolic arterial pressure or heart rate differing .20%

from baseline), autonomic (sweating, flushing, and salivat-

ing), and somatic signs (movement and swallowing), the

remifentanil infusion was increased successively until

symptoms were resolved. Standard treatment of blood loss

and fluid replacement strategy were used if necessary.

As part of the post-anaesthetic pain management, piri-

tramide 0.05 mg kg21 i.v. and a short infusion of metami-

zole 15 mg kg21 were administered 20 min before the

estimated end of surgery as part of post-anaesthetic pain

management. Ten minutes before the end of surgery, the

inhaled anaesthetics were reduced to 0.5 age-adapted

MAC. Anaesthesia was maintained until all surgical inter-

ventions were completed, the haemodynamics (systolic

arterial pressure or heart rate) were stable, and full recov-

ery of neuromuscular block was reached (TOF-Watch

SXw, Organon Teknika, Eppelheim, Germany). From this

point, return of spontaneous breathing was facilitated by

allowing end-expiratory carbon dioxide to increase up to

6.6 kPa. After full recovery of the upper airway reflexes

and return of sufficient spontaneous breathing [ventilatory

frequency .8 breaths min-1 and oxygen saturation (SaO2)

.95% at FIO2100%], the patients’ tracheas were

extubated.

Statistical analysis

Parametric data were tested with one-way ANOVA and pre-

sented as means and standard deviation, as means and

standard error of the means, as median and range, or as

means and 95% confidence intervals, accordingly.

Categorical data were analysed with the two-tailed

Pearson’s x2 test and are given as numbers and per cents

of total. Statistical analysis was performed using SPSS

Software Version 16.0 (SPSS Inc., Chicago, IL, USA).

GraphPad PRISMw (GraphPad Software Inc., La Jolla,

CA, USA) was used to generate the figures.

The sample size was calculated for the primary outcome

parameters with a power of b¼0.9 and a significance level

of a¼0.05, considering a difference of 20% as relevant.

Mean values and standard deviations were taken from a

previous study in the elderly assessing the TAP (patients

aged 65–75 yr) with the subtests Alertness, Divided

Attention, and Working Memory.6 The power was calcu-

lated for the subtests of the TAP (Alertness, Divided

Attention, and Working Memory) with n¼6–21 per

group. The trial size was determined with a total of 40

patients per group to compensate for possible drop-outs.

The power calculation was performed using nQuery

Advisorw, Version 4.0 (Statistical Solutions, Saugus, MA,

USA).

Results

A total of 80 patients were included in this study, 40 in

the desflurane group and 40 in the sevoflurane group. Both

study groups were comparable with regard to age, height,

weight, gender, education level, ASA status, and Apfel

score.14

At the 6–8 h postoperative assessment, the TAP was

completed by 31 patients in the desflurane group and 33

patients in the sevoflurane group, at the 66–72 h assess-

ment by 27 and 30 patients. The reasons for drop-outs

were refusal of postoperative testing, not receiving the

allocated intervention, and discharge from hospital before

the second assessment.

The vital parameters systolic and diastolic arterial

pressure, heart rate, and Sao2were comparable between the

groups, the latter being at least 98% at all times. The

mean remifentanil consumption was comparable in both

groups. The average anaesthetic gas concentration was

4.32 (0.26)% in the desflurane group and 1.27 (0.11)% in

the sevoflurane group. Type of surgery and duration of

anaesthesia did not differ between the groups. Baseline

assessment and the assessment of the TAP were performed

at comparable time points (Table 1).

Patients in the desflurane group recovered significantly

faster as indicated by the ‘time to open eyes’ (P¼0.05)

and ‘time to extubation’ (P¼0.05). No difference was seen

between the ‘time to react on demand’ and ‘time to time

(actual day) and spatial orientation’. Length of stay in the

PACU and intra- and postoperative opioid consumption

were comparable between the groups (Table 1). In the

PACU, the modified Aldrete scores were similar in both

groups. The following scores were in favour of desflurane:

vigilance at arrival (P¼0.01), vigilance at 5 min

(P¼0.02), well-being at discharge (P¼0.03), and energy at

30 and 45 min (P¼0.05 and 0.04) (Table 2).

Baseline assessment of cognitive function showed no

difference between the two groups. The 6–8 and 66–72 h

postoperative tests for cognitive function and well-being

assessed with the Paper–Pencil Tests and the ones

assessed with the TAP were normalized to the 12–24 h

preoperative baselines. The following subtests of the

Paper–Pencil Tests showed significant differences in

favour of desflurane: Well-being at 6–8 h (P¼0.04), DST

at 6–8 h (P¼0.02), and Trail making Test A at 66–72 h

(P¼0.05) (Fig. 1). There was no difference for the TAP

between the two groups (Fig. 2).

Regarding both, the Paper–Pencil Tests and the TAP,

the numbers with a decline of 20% from the 12–24 h pre-

operative baseline did not differ between the desflurane

and the sevoflurane groups at the 6–8 and 66–72 h post-

operative assessment (Table 3). Furthermore, the incidence

of POCD (defined as being a 20% decline in 20% of both

the Paper–Pencil Tests and the TAP)11 was similar at the

6–8 h (desflurane 39% and sevoflurane 36%; P¼0.67) and

66–72 h (desflurane 41% and sevoflurane 47%; P¼0.96)

time points.

The marks for patients’ self-evaluation of the anaesthe-

sia procedure assessed 6–8 h after operation were signifi-

cant in favour of the desflurane group (P¼0.03). Also the

Cognitive function, desflurane, and sevoflurane

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question of repetition of the same anaesthesia for further

operations showed more positive answers for the desflur-

ane group (P¼0.05).

Discussion

In the present study, we compared early cognitive function

in the elderly after desflurane or sevoflurane anaesthesia.

The TAP showed no differences in incidence and severity

between the desflurane and the sevoflurane groups at the

6–8 and 66–72 h assessment. Compared with the base-

line, the incidence of POCD was high in both groups (des-

flurane 39% and sevoflurane 36% at the 6–8 h assessment

and at 66–72 h assessment desflurane 41% and sevoflur-

ane 47%). However, in various subtests of the Paper–

Pencil Tests, significant improvements for desflurane

(Well-being scale, DST, and Trail making Test A) could

be detected. Emergence times such as ‘time to open eyes’

and ‘time to extubation’ were faster after desflurane anaes-

thesia. The scores for vigilance, well-being, and energy in

the PACU turned out beneficial to some extent in the des-

flurane group. Patients’ self-evaluation of anaesthesia was

in favour of desflurane.

The power was calculated considering a difference of

20% as relevant. However, a difference of 10–15% might

be clinically more realistic. Taking this into account, the

Table 2 Post-anaesthetic care unit. All values are recorded after surgery at arrival (A) in the PACU, after 5 (5), 15 (15), 30 (30), 45 (45) min, and at discharge

from the PACU (D). Modified Aldrete scores are presented as mean (SD). Vigilance, well-being, and energy after anaesthesia are shown in numbers and per cent

of total (in parentheses). Vigilance is rated as awake (A), tired (T), and sleeping (S). Well-being is classified as excellent (E), good (G), fair (F), and poor (P).

Energy is divided into normal (N), fair (F), and poor (P)

AldreteA Aldrete5 Aldrete15 Aldrete30 Aldrete45 AldreteD

Desflurane 9.5 (0.9) 9.5 (0.9) 9.5 (0.7) 9.5 (0.8) 9.6 (0.6) 9.8 (0.5)

Sevoflurane 9.3 (0.9) 9.3 (0.9) 9.4 (0.99) 9.5 (0.9) 9.4 (0.9) 9.9 (0.4)

P-value 0.23 0.46 0.38 0.67 0.55 0.55

VigilanceA (A/T/S) Vigilance5 (A/T/S) Vigilance15 (A/T/S) Vigilance30 (A/T/S) Vigilance45 (A/T/S) VigilanceD (A/T/S)

Desflurane 4/27/5 (11/75/14) 4/27/6 (11/73/17) 4/27//6 (11/73/16) 3/27/5/ (9/77/14) 2/21/4 (7/78/15) 4/27/5 (11/75/14)

Sevoflurane 4/17/18 (10/44/46) 5/17/17 (13/44/44) 5/19/15/ (13/49/38) 6/20/13 (15/51/33) 5/17/10 (16/53/31) 9/23/7 (23/59/18)

P-value 0.01 0.02 0.07 0.06 0.14 0.29

Well-beingA (E/G/F/P) Well-being5 (E/G/F/P) Well-being15 (E/G/F/P) Well-being30 (E/G/F/P) Well-being45 (E/G/

F/P)

Well-beingD (E/G/

F/P)Desflurane 0/16/18/2 (0/44/50/6) 0/18/16/3 (0/49/43/8) 1/20/11/5 (3/54/39/14) 1/19/12/3 (3/54/34/9) 0/15/10/2 (0/56/37/7) 0/23/10/3 (0/64/28/

8)

Sevoflurane 0/13/20/6 (0/33/51/15) 0/13/20/6 (0/33/51/15) 0/13/21/5 (0/33/54/13) 0/13/22/4 (0/33/56/10) 0/10/19/3 (0/31/59/9) 0/16/22/4 (0/41/56/

10)

P-value 0.31 0.33 0.13 0.17 0.16 0.03

EnergyA (N/F/P) Energy5 (N/F/P) Energy15 (N/F/P) Energy30 (N/F/P) Energy45 (N/F/P) EnergyD (N/F/P)

Desflurane 2/17/17 (6/47/47) 3/16/17 (8/44/47) 4/18/14 (11/50/39) 4/21/9 (12/62/26) 2/17/7 (8/65/27) 5/23/8 (14/64/22)

Sevoflurane 1/11/27 (3/28/69) 1/11/27 (3/28/69) 0/16/23 (0/41/59) 2/16/21 (5/41/54) 1/12/19 (3/38/59) 3/18/18 (8/46/46)

P-value 0.15 0.13 0.04 0.05 0.04 0.08

Table 1 Anaesthesia data, emergence from anaesthesia, and time points of testing. Average anaesthetic gas concentration is presented as mean (SD). Type of

surgery is given in number and percentage of total in parentheses. Anaesthesia and PACU times are displayed as means with the upper and lower 95%

confidence interval. Intra- and postoperative piritramide consumption is presented as mean (SD). Emergence from anaesthesia: all time points are presented in

minutes as mean and lower and upper 95% confidence intervals in parentheses. Time points of testing are shown in hours and minutes (h:min) with the upper

and lower 95% confidence interval

Desflurane Sevoflurane P-value

Average anaesthetic gas concentration (%) 4.32 (0.26) 1.27 (0.11) —

Type of surgery 0.48

Trauma 6 (16%) 7 (18%)

ENT 4 (11%) 2 (5%)

Gynaecology 8 (22%) 5 (13%)

Urology 7 (19%) 8 (21%)

Neurosurgery 12 (32%) 17 (44%)

Anaesthesia time (min) 127 (105–149) 152 (133–170) 0.09

PACU time (min) 66 (54–78) 71 (40–80) 0.58

Intraoperative piritramide (mg) 5.2 (1.9) 5.9 (2.4) 0.20

Postoperative piritramide (mg) 7.2 (4.1) 7.9 (4.7) 0.62

Time to open eyes (min) 7.4 (6.2–8.6) 9.2 (7.8–10.6) 0.05

Time to react on demand (min) 7.7 (6.5–8.9) 9.2 (7.7–10.7) 0.12

Time to extubation (min) 7.7 (6.5–8.9) 9.4 (8.0–10.8) 0.05

Time to time (actual day) and spatial orientation (min) 10.8 (9.3–12.2) 13.4 (9.5–17.3) 0.21

Baseline assessment (h:min) 18:12 (17:47–18:37) 18:36 (18:16–18:55) 0.13

6–8 h postoperative assessment (h:min) 15:26 (13:54–16:57) 14:43 (13:05–16:21) 0.52

66–72 h postoperative assessment (h:min) 15:16 (13:48–16:45) 15:15 (13:55–16:35) 0.98

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study might be underpowered. Further limitations of the

study are: patients above 75 yr and those with cardiac and

endocrine disease are excluded. However, these patients

are at high risk to develop POCD. This fact weakens the

external validity of the study. In addition, if the

Bonferroni correction is applied, as the study has several

outcome parameters, all test results fail to be significant.

The average anaesthetic gas concentration was 4.32

(0.26)% in the desflurane group and 1.27 (0.11)% in the

sevoflurane group. Both gas concentration ranges are in

line with the age-adapted MAC described by Nickalls and

Mapleson.13 As the anticipated operation is a stress factor

for the patients, the timing of the baseline assessment is

critical and was therefore assessed in a standardized

manner 12–24 h before operation in the hospital. Heavner

and colleagues4 used a baseline assessment just before pre-

medication was given, but this could have influenced the

baseline testing even more.

Learning by repeated postoperative assessments may

represent a strong confounder. Retest reliability for the

TAP has been shown before, but not for such a short inter-

val as used in our study.6 Looking at the Paper–Pencil

Baseline 6–8 h 66–72 h






400120

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0

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P=0.013

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P=0.008

P=0.010

P=0.012 P=0.001

P=0.008

P=0.001

P=0.03

$

P=0.003

P=0.032P=0.014

*

A B

C D

E F

§

Fig 1 Cognitive function and well-being assessed with Paper–Pencil Tests. All values are shown as mean (SEM) and display the change in per cent at

6–8 and 66–72 h postoperative normalized to the 12–24 h preoperative baseline. All ordinates are in per cent. (A) Well-being Test BF-S (an increase

in per cent presents a decline in well-being). For (B–F) an increase in per cent shows an increase in outcome: (B) DST, (C) DSST, (D) Trail Making Test

A, (E) Trail Making Test B, and (F) six-item short-form of the Spielberg State-Trait Anxiety Inventory (STAI). Black lines and open diamonds display

the sevoflurane group and grey lines and open circles present the desflurane group; *P¼0.04; §P¼0.02; $P¼0.05. An increase in baseline might be due

to a learning effect in (B–F).


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130A B

C D

E F

G H

I J

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P=0.015

Baseline 6–8 h 66–72 h Baseline 6–8 h 66–72 h





Fig 2 Cognitive function assessed with the TAP. All values are mean (SEM) and display the change in per cent at 6–8 and 66–72 h postoperative

normalized to the 12–24 h preoperative baseline. All ordinates are in per cent. For (A–J), an increase in per cent shows an increase in outcome. All

figure pairs show first reaction time and then valid reaction. (A and B) Alertness; (C and D) Divided Attention; (E and F) Visual Scanning; (G and H)

Working Memory; (I and J) Reaction Change. Black lines and black open symbols stand for the sevoflurane group and grey lines and grey open circles

display the desflurane group.

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Tests, we used complementing versions when available

(e.g. Trail Making Test).

In this study, elderly patients underwent surgery known

to be associated with a high risk of POCD. The total level

of POCD seems to be similar to earlier studies performed

in the same age group.2 3 However, these data are limited

since different methods have been used to measure and

define POCD.

By using the DSST, Heavner and colleagues4 could not

find any difference between general anaesthesia with des-

flurane or sevoflurane in the elderly. Heavner and col-

leagues attributed their findings to the limitations of the

DSST. We used enhanced testing instruments and added

the computerized TAP with its subtests Alertness, Divided

Attention, Visual Scanning, Working Memory, and

Reaction Change in our investigation. The TAP is estab-

lished to measure attention and was used in previous

studies.5 6 It was designed to analyse cognitive functions.

The increase in the subtest Alertness indicates temporary

deficits in attention whereas general slowness can be distin-

guished.15 16 Performing two or more different duties sim-

ultaneously is often needed in daily routine. This is

examined by dual-tasks in the subtest Divided Attention.17

The subtest Visual Scanning is important because it

measures continuous attention. In the concept of ‘Working

Memory’, the short-term memory is the essential instance

to control information flow for good attentional perform-

ance.18 – 21 Using the subtest Working Memory, a continu-

ous control of the information flow through short-term

memory is tested. As mental flexibility seems to be an

important aspect of cognitive functioning, this is assessed

by the subtest Reaction Change.20 21

In this study, emergence times for ‘time to open eyes’ and

‘time to extubation’ for desflurane were significantly faster

than those for sevoflurane. The study by Chen and

colleagues22 described a similar recovery of cognitive func-

tion for desflurane and sevoflurane anaesthesia in the

elderly.

In conclusion, there was no difference in Alertness,

Divided Attention, Visual Scanning, Working Memory, and

Reaction change 6–8 h and 66–72 h after operation between

desflurane and sevoflurane anaesthesia. Despite some advan-

tages for desflurane in three subtests of the Paper–Pencil

Tests (Well-being scale at 6–8 h, DST at 6–8 h, and Trail

making Test at 66–72 h), anaesthesia in the elderly with des-

flurane or sevoflurane seems to be similar regarding recov-

ery. Emergence times from anaesthesia for ‘time to open

eyes’ and ‘time to extubation’ in the elderly with desflurane

were faster than those with sevoflurane. Patients’ satisfaction

after anaesthesia was in favour of desflurane.

AcknowledgementsWe would like to thank Jan-Hinrich Baumert and Oliver Kunitz whohelped in initiating this trial.

Funding

This work was funded in parts by Baxter Germany GmbH

(financial support). None of the authors received any cor-

porate support, honoraria, etc. from the above-mentioned

sponsor of this study.

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Table 3 Twenty per cent deviation to the 12–24 h preoperative assessment in cognitive function and well-being assessed with both the Paper–Pencil Tests and

the TAP. Values present numbers and per cent of total in parentheses with a deviation .20% to the normalized 12–24 h preoperative values. BF-S, Well-being

Test BF-S; DST, Recall of Digit Span; DSST, Digit-Symbol-Substitution Test; TMT A, Trail Making Test A; TMT B, Trail Making Test B; STAI, short-form of

the Spielberg State-Trait Anxiety Inventory; RT, mean reaction time; VR, valid reaction

6–8 h postoperative >20% 66–72 h postoperative >20%

Desflurane Sevoflurane P-value Desflurane Sevoflurane P-value

BF-S 11 (37) 19 (61) 0.07 5 (19) 8 (32) 0.21

DST 4 (13) 7 (22) 0.51 3 (11) 7 (23) 0.31

DSST 4 (14) 6 (19) 0.73 0 (0) 2 (7) 0.50

TMT A 6 (21) 5 (16) 0.75 5 (19) 1 (3) 0.09

TMT B 8 (33) 7 (25) 0.55 2 (8) 3 (11) 1.0

STAI 9 (27) 5 (15) 0.24 2 (7) 4 (13) 0.68

Alertness RT 12 (40) 9 (28) 0.42 5 (20) 3 (10) 0.45

Alertness VR 3 (10) 0 (0) 0.11 2 (8) 0 (0) 0.22

Divided Attention RT 1 (3) 1 (3) 1.0 1 (4) 1 (3) 1.0

Divide Attention VR 4 (13) 4 (13) 1.0 4 (15) 4 (13) 1.0

Visual Scanning RT 4 (15) 9 (29) 0.23 2 (8) 5 (19) 0.43

Visual Scanning VR 0 (0) 1 (3) 1.0 1 (4) 0 (0) 0.49

Working Memory RT 11 (44) 6 (22) 0.14 4 (18) 9 (36) 0.21

Working Memory VR 6 (24) 7 (27) 1.0 3 (14) 1 (4) 0.33

Reaction Change RT 2 (7) 5 (16) 0.43 1 (4) 2 (7) 1.0

Reaction Change VR 0 (0) 0 (0) — 0 (0) 0 (0) —


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