Preoperative Management of the Geriatric Patient: Frailty and Cognitive Impairment Assessment

The EUropean PErioperative MEdical Networking (EUPEMEN) project and recommendations for perioperative care in colorectal surgery: a quality improvement study

BACKGROUND

Despite consensus supporting enhanced recovery programs, their full implementation in such a context is difficult due to conventional practices within various groups of professionals. The goal of the EUropean PErioperative MEdical Networking (EUPEMEN) project was to bring together the expertise and experience of national clinical professionals who have previously helped deliver major change programs in their countries and to use them to spread enhanced recovery after surgery protocols (ERAS) in Europe. The specific aim of this study is to present and discuss the key points of the proposed recommendations for colorectal surgery.

MATERIALS AND METHODS

Five partners from university hospitals in four European countries developed the project as partners. Following a non-systematic review of the literature, the European consensus panel generated a list of recommendations for perioperative care in colorectal surgery. A list of recommendations was formulated and distributed to collaborators at each center to allow modifications or additional statements. These recommendations were then discussed in three consecutive meetings to share uniform ERAS protocols to be disseminated.

RESULT

The working group developed (1) the EUPEMEN online platform to offer, free of charge, evidence-based standardized perioperative care protocols, learning activities, and assistance to health professionals interested in enhancing the recovery of their patients; (2) the preparation of the EUPEMEN Multimodal Rehabilitation manuals; (3) the training of the trainers to teach future teachers; and (4) the dissemination of the results in five multiplier events, one for each partner, to promote and disseminate the protocols.

CONCLUSION

The EUPEMEN project allowed the sharing of the expertise of many professionals from four different European countries with the objective of training the new generations in the dissemination of ERAS protocols in daily clinical practice through a new learning system. This project was proposed as an additional training tool for all the enhanced recovery program teams.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery

INTRODUCTION

Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery.

AIM

To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors.

METHODS

We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery.

RESULTS

Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors.

CONCLUSIONS

Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

The EUPEMEN (EUropean PErioperative MEdical Networking) Protocol for Bowel Obstruction: Recommendations for Perioperative Care

Mechanical bowel obstruction is a common symptom for admission to emergency services, diagnosed annually in more than 300,000 patients in the States, from whom 51% will undergo emergency laparotomy. This condition is associated with serious morbidity and mortality, but it also causes a high financial burden due to long hospital stay. The EUPEMEN project aims to incorporate the expertise and clinical experience of national clinical specialists into development of perioperative rehabilitation protocols. Providing special recommendations for all aspects of patient perioperative care and the participation of diverse specialists, the EUPEMEN protocol for bowel obstruction, as presented in the current paper, aims to provide faster postoperative recovery and reduce length of hospital stay, postoperative morbidity and mortality rate.

The Impact of Socioeconomic Factors and Geriatric Syndromes on Frailty among Elderly People Receiving Home-Based Healthcare: A Cross-Sectional Study

Purpose: To evaluate frailty and its relationship with geriatric syndromes in the context of socioeconomic variables. Patients and Methods: In this cross-sectional study, elderly people aged 65 years old and over who received homecare in the reference region of Crete, Greece, were enrolled. Geriatric syndromes such as frailty, dementia, and depression were evaluated using the SHARE-Frailty Index (SHARE-Fi), the Montreal Cognitive Assessment (MoCA), and the Geriatric Depression Scale (GDS), respectively. Level of education, annual individual income, disability in Activities of Daily Living (ADL) and homebound status were also assessed as ‘socioeconomic factors.’ Results: The mean age of 301 participants was 78.45 (±7.87) years old. A proportion of 38.5% was identified as frail. A multiple logistic regression model revealed that elderly people with cognitive dysfunction were more likely to be frail (OR = 1.65; 95% CI: 0.55−4.98, p = 0.469) compared to those with normal cognition, but this association was not significant. Although elderly people with mild depression were significantly more likely to be frail (OR = 2.62; CI: 1.33−5.17, p = 0.005) compared to those with normal depression, the association for elderly people with severe depression (OR = 2.05, CI: 0.80−5.24, p = 0.134) was not significant. Additionally, comorbidity (OR = 1.06, CI: 0.49−2.27, p = 0.876) was not associated with frailty, suggesting that comorbidity is not a risk factor for frailty. In addition, patients with mild depression were significantly more likely to report frailty (OR = 2.62, CI:1.33−5.17, p = 0.005) compared to those with normal depression, whereas elders with an annual individual income (>EUR 4500) were less likely to be frail (OR = 0.45, CI: 0.25−0.83, p = 0.011) compared to those with <EUR 4500 per year. Conclusions: Our data analysis shows that higher annual individual income and mild depression were independently associated with frailty, suggesting that a lower poverty threshold and mild depression are risk factors for frailty.

The Future of Assessing Frailty in the Patient With Advanced Heart Failure: A Review of Current Literature

Frailty is becoming an important component of health care outcomes in patients with a diagnosis of heart failure. A literature search was completed to determine whether a best practice guideline existed to assess frailty in patients who were considering ventricular assist device placement. The literature search revealed that best practice guidelines did not exist. A second comprehensive literature search was completed specifically for frailty including the definition, criteria, assessment, and outcomes. The studies revealed that there were challenges with defining frailty, the age of frailty, assessments tools, and study designs. Cardiologists are primarily interested in screening for frailty, but other physician specialty practices are interested in a frailty screening tool as well. This article discusses the inconsistent research studies and the need for a valid and reliable tool to assess for frailty. It is important that nurse leaders and those working with heart failure patients determine the best practice guidelines for assessing frailty.

Determination of risk factors of postoperative pneumonia in elderly patients with hip fracture: What can we do?

BACKGROUND

Postoperative pneumonia is a serious complication in elderly patients with hip fracture. It is necessary to identify the influencing factors of postoperative pneumonia in patients with hip fracture.

METHODS

Elderly patients with hip fractures admitted to a tertiary hospital in China from January 1, 2020 to August 31, 2021 were included. The characteristics of patients with and without postoperative pneumonia were evaluated and compared. Logistic multivariate regression analyses were conducted to assess the risk factors of postoperative pneumonia.

RESULTS

267 patients with hip fracture were included, the incidence of postoperative pneumonia in patients with hip fracture was 13.11%. There were significant differences in the age, diabetes mellitus, anemia, hypoalbuminemia, anesthesia method and duration of surgery between infection and no infection group, no significant differences in the gender, BMI, hypertension, hyperlipidemia, type of fracture, preoperative oxygen saturation, white blood cell count, platelet count, red blood cell count, creatinine, alanine aminotransferase, aspartate aminotransferase, estimated blood loss during surgery were detected between infection and no infection group. Logistic regression analysis showed that age≥70y (OR2.326, 95%CI1.248~3.129), diabetes mellitus (OR2.123, 95%CI1.021~3.551), anemia (OR3.199,95%CI1.943~5.024), hypoalbuminemia (OR2.377, 95%CI1.211~3.398), general anesthesia (OR1.947, 95%CI1.115~3.038), duration of surgery≥120min (OR1.621, 95%CI1.488~2.534) were the risk factors of postoperative pneumonia in elderly patients with hip fracture (all p<0.05). Escherichia Coli (33.33%), Klebsiella pneumoniae (28.57%), Staphylococcus aureus (21.43%) were the most common bacteria of pulmonary infection.

CONCLUSION

There are many risk factors for postoperative pneumonia in elderly patients with hip fractures after surgery. In clinical practice, medical workers should take targeted interventions for those risk factors to reduce postoperative pneumonia.

Screening for Mild Cognitive Impairment in the Preoperative Setting: A Narrative Review

Cognitive impairment predisposes patients to the development of delirium and postoperative cognitive dysfunction. In particular, in older patients, the adverse sequelae of cognitive decline in the perioperative period may contribute to adverse outcomes after surgical procedures. Subtle signs of cognitive impairment are often not previously diagnosed. Therefore, the aim of this review is to describe the available cognitive screeners suitable for preoperative screening and their psychometric properties for identifying mild cognitive impairment, as preoperative workup may improve perioperative care for patients at risk for postoperative cognitive dysfunction. Electronic systematic and snowball searches of PubMed, PsycInfo, ClinicalKey, and ScienceDirect were conducted for the period 2015-2020. Major inclusion criteria for articles included those that discussed a screener that included the cognitive domain 'memory', that had a duration time of less than 15 min, and that reported sensitivity and specificity to detect mild cognitive impairment. Studies about informant-based screeners were excluded. We provided an overview of the characteristics of the cognitive screener, such as interrater and test-retest reliability correlations, sensitivity and specificity for mild cognitive impairment and cognitive impairment, and duration of the screener and cutoff points. Of the 4775 identified titles, 3222 were excluded from further analysis because they were published prior to 2015. One thousand four hundred and forty-eight titles did not fulfill the inclusion criteria. All abstracts of 52 studies on 45 screeners were examined of which 10 met the inclusion criteria. For these 10 screeners, a further snowball search was performed to obtain related studies, resulting in 20 articles. Screeners included in this review were the Mini-Cog, MoCA, O3DY, AD8, SAGE, SLUMS, TICS(-M), QMCI, MMSE2, and Mini-ACE. The sensitivity and specificity range to detect MCI in an older population is the highest for the MoCA, with a sensitivity range of 81-93% and a specificity range of 74-89%. The MoCA, with the highest combination of sensitivity and specificity, is a feasible and valid routine screening of pre-surgical cognitive function. This warrants further implementation and validation studies in surgical pathways with a large proportion of older patients.

Assessment of long-term cognitive dysfunction in older patients who undergo heart surgery

INTRODUCTION

Older patients are more likely to have cognitive dysfunction, and a great proportion of patients undergone surgical procedures are older adults. Postoperative cognitive dysfunction (POCD) has been shown as a consistent complication after major surgical procedures such as heart surgery.

AIM

To determine the presence of long-term POCD in ≥65-year-old patients undergoing coronary artery bypass grafting and aortic valve replacement, and to establish related risk factors.

METHODS

We prospectively and sequentially included 44 patients with coronary disease and aortic stenosis scheduled for heart surgery. Follow-up of all patients was standardized and a neurocognitive evaluation were performed preoperatively and at 1, 6 and 12 months after surgery.

RESULTS

Patients experienced a significantly postoperative cognitive dysfunction (33.5%, 63.4% and 38.9% at 1, 6 and 12 months, respectively) from baseline (20.5%). Patient-associated aspects such as age (p<0.01), history of smoking (p<0.01), arterial hypertension (p=0.022), diabetes mellitus (p=0.024), heart failure (p=0.036) and preoperative cognitive dysfunction (p<0.01), and surgery-associated aspects such as EuroSCORE (p<0.01) and operation time (p<0.01) were identified as related risk factors.

CONCLUSIONS

Older patients who underwent heart surgery had long-term POCD. Both patient- and surgery-related risk factors were established as related risk factors. These findings suggest that the prevalence of cognitive dysfunction after cardiac surgery in older patients could be related to a possible progression to dementia. In addition, many of the risk factors identified may be modifiable but in practice, these patients are not attended to for their possible cognitive impairment.

Prehabilitation: metabolic considerations

PURPOSE OF REVIEW

The major components of ERAS attenuate the inflammatory response and modulate metabolism in direction of sparing body protein and preserving function. However, these perioperative interventions might have limited effectiveness on postoperative outcomes if preoperative risk factors are not addressed and optimized.

RECENT FINDINGS

The preoperative metabolic perturbations characterized by insulin resistance and sarcopenia might predispose patients to a higher degree of postoperative catabolism. High-risk populations for such metabolic disturbances include elderly and frail patients, and patients with metabolic syndrome. Research on the effect of prehabilitation on perioperative metabolism is limited, but recent findings suggest that interventions designed to improve insulin sensitivity prior to surgery might represent a promising therapeutic target to minimize surgical complications.

SUMMARY

The present paper will discuss the metabolic implications of modulating preoperative risk factors with elements of multimodal prehabilitation, such as exercise training and nutrition.