Auricular Acupunctures are Effective for the Prevention of Postoperative Agitation in Old Patients

Postoperative cognitive problems and delirium are not uncommon in the elderly. We reported four cases in which auricular acupunctures on the ‘Shenmen’ and ‘Point Zero’ points successfully managed postoperative problematic behaviors of the three patients with dementia and the one patient postoperatively demonstrating an agitated behavior.


Introduction
Persistent postoperative cognitive problems and delirium are not uncommon in the elderly (1). Since postoperative agitation in the patients can lead to serious consequences for patients such as injury, hemorrhage and removal of drain tubes and catheters (2), physical and chemical restraints are commonly applied to restrain the patients. However, more humane methods are needed for the treatment.
Anesthesia is reportedly associated with thereafter the worsening of neurodegenerative disorders such as Alzheimer's disease (3,4). Also, prior cognitive impairment and neurodegenerative disorder are significant risk factors for postoperative delirium (5,6). We report four cases in which auricular acupuncture at tranquilizing points successfully managed postoperative problematic behavior in patients with prior agitation.

Case Report
After obtaining approval from the Ethics Committees of Toki General Hospital, family members of each patient consented to auricular acupuncture treatment and the publication of this case report. Table 1 shows the blood cell, blood gas, electrolyte and biochemical data of postoperative day (POD) 1 of the four cases. Clinical behavioral features during pre-and postoperation were evaluated by nurses. Observations of subjects was conducted each shift and recorded using the delirium observation screening (DOS) that is developed based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnostic criteria (6)(7)(8). The DOS scale is with 13 items ( Table 2) that can be rated as present or absent in less than 5 min. The highest total score is 13. Three or more points indicate a delirium. Table 3 shows the changes of the DOS.

Case 1
Auricular acupuncture for a 95-year-old man with dementia after cholecystectomy. A 95-year-old and 51 kg man was scheduled to have cholecystectomy. His medical history included Alzheimer's disease and hypertension. He showed aggressive behavior not only for himself but also for the other. After the placement of an epidural catheter, general anesthesia was induced with fentanyl 50 mg and propofol 70 mg. Anesthesia was then maintained using 1.5-2% sevoflurane and epidural 2% lidocaine 8 ml. After the uneventful operation, he received occlusive press needles (Pyonex-small; Seirin, Japan) at the 'Shenmen' and 'Point Zero' points at both auricles (9)(10)(11). The patient received fentanyl 15 mg h À1 and 1% lidocaine 2 ml h À1 epidurally for 2 days. We changed press needles every 3 days until POD 9. During the treatment, he did not show aggressive behavior. Although he resumed aggressive behavior on POD 10, he uneventfully discharged 3 weeks later.

Case 2
Auricular acupuncture for a 74-year-old woman with dementia after gastrectomy: A 74-year-old and 45 kg woman was scheduled to have distal gastrectomy.
She experienced delusion and showed wandering behavior. After the placement of an epidural catheter, general anesthesia was induced with fentanyl 50 mg and propofol 100 mg. Anesthesia was then maintained using 1.5-2% sevoflurane and epidural 2% lidocaine 8 ml. After the uneventful operation, she received auricular press needles at the 'Shenmen' and 'Point Zero' points at both auricles. The patient received fentanyl 20 mg h À1 and 1% lidocaine 2 ml h À1 epidurally for 2 days. We left the press needles until POD 7. During and after the treatment, she did not show wandering behavior. She uneventfully discharged 3 weeks later.

Case 3
Auricular acupuncture for an 81-year-old woman with dementia after thyroidectomy: An 81-year-old and 42 kg woman was scheduled to have subtotal thyroidectomy. Her medical history included dementia, diabetes mellitus and hypertension. She showed a decline in cognitive function. General anesthesia was induced with fentanyl 100 mg and propofol 50 mg. Anesthesia was then maintained using 1.5-2% sevoflurane with 50% nitrous oxide in oxygen and further intravenous fentanyl 10 mg. After the uneventful operation, she received occlusive auricular press needles at the 'Shenmen' and 'Point Zero' points at both auricles. We changed press needles every 3 days until POD 9. During and after the treatment, she did not show problematic behaviors. She discharged 3 weeks later.

Case 4
Auricular acupuncture for a 72-year-old and postoperatively agitated woman: a 72-year-old and 48 kg woman was scheduled to have distal gastrectomy. After the placement of an epidural catheter, general anesthesia was induced with fentanyl 100 mg and propofol 100 mg. Anesthesia was then maintained using 1.5-2% sevoflurane and epidural 1.5% lidocaine 14 ml. After the uneventful operation, the patient received fentanyl 20 mg h À1 and 1% lidocaine 2 ml h À1 epidurally for 3 days. She became agitated and demonstrated aggressive behavior on POD 1. She was extremely difficult to restrain. She received occlusive auricular press needles at the 'Shenmen' and 'Point Zero' points at both auricles. Within a few hours, she became calm and showed no further signs of agitation. We changed press needles every 3 days until POD 9. During and after the treatment, she did not show agitated behaviors. She uneventfully discharged 3 weeks later.
hemorrhage and removal of drain tubes and catheters requiring physical and chemical restraint, postoperative progression of dementia and aggression is a challenge for anesthesiologists. Persistent postoperative cognitive problems occur in the elderly (1) and anesthesia is associated with thereafter the worsening of neurodegenerative disorders such as Alzheimer's disease (2), resulting in postoperative problematic behaviors such as aggression and agitation. Also, blood urea levels and blood balance in the postoperative period were found to be significant risk factors for delirium (5,6). We therefore described these data in this case report, and the data were within normal limits. Non-pharmacological interventions such as acupuncture and acupressure applied on the traditionally used acupuncture points have been used for perioperative management (12)(13)(14). These interventions also result in tranquilization and decrease anxiety not only in healthy volunteers but also in patients (15,16). Especially, auricular acupuncture at tranquilizing points reduces anxiety among healthy volunteers and adult patients undergoing surgery (10,11).
The present agitated patients received occlusive auricular press needles at the 'Shenmen' point, tranquilizing the mind, and the 'Point Zero' point, generating a general homeostatic balance and supporting the actions of other auricular points, at both auricles (9) and then the patients did not show problematic behaviors such as aggression and agitation (that could have led serious consequences) during the application of the auricular press needles. Their tranquility might have been obtained by chance. However, acupuncture reduces behavioral hyperactivity in rats sensitized to morphine (17). Also, a study showed that acupressure decreases agitation behavior in patients with dementia (18). In traditional Chinese medicine, it is believed that dementia results from disorders of the five organs (including liver, heart, spleen, lung and kidney). Acupoint stimulation could regulate these five organs, thereby controlling agitated behaviors (18) (Fig. 1). Moreover, we planned a randomized controlled trial about the effect of auricular acupuncture on postoperative behavior in elderly patients and the study is under investigation. Almost all patients who received occlusive auricular press needles at the Shenmen and Point Zero points did not show problematic behaviors during postoperative period. We therefore postulate that auricular acupuncture at the specific points would be useful for the management of postoperative delirium in the elderly.
In summary, auricular acupuncture successfully managed postoperative problematic behaviors in old patients. This technique may have a potential to control old patients showing an agitated behavior.