Cognitive Prehabilitation: How Can We Counter Neurocognitive Frailty?

Prehabilitation to mitigate postintensive care syndrome in surgical patients: The rationale for a peri-critical illness pathway involving anaesthesiologists and intensive care physicians

The post-intensive care syndrome (PICS) refers to the long-term physical, psychological and cognitive impairments experienced by intensive care unit (ICU) survivors, while PICS-Family (PICS-F) affects their family members. Despite preventive strategies during the ICU stay, PICS remains a significant concern impacting survivors' quality of life, increasing the healthcare costs, and complicating recovery. Prehabilitation offers a promising approach to mitigating PICS and PICS-F, especially when the ICU stay can be anticipated, such as in the case of major surgery. Recent literature indicates that prehabilitation - interventions designed to enhance patients' functional capacity before critical illness - may mitigate the risk and severity of PICS. Studies have demonstrated that prehabilitation programs can improve muscle strength, reduce anxiety levels and enhance overall quality of life in ICU survivors. Family prehabilitation (prehabilitation-F) is also introduced as a potential intervention to help families to cope with the stress of critical illness. This article aims to explore the role of multimodal prehabilitation and post-ICU follow-up in preventing and managing PICS and PICS-F, focusing on improving patient outcomes, supporting families and optimising healthcare resources. Combining prehabilitation with post-ICU follow-up in peri-critical care clinics could streamline resources and improve outcomes, creating a holistic care pathway. These clinics, focused on both pre-ICU and post-ICU care, would thus address PICS from multiple angles. However, the heterogeneity of patient populations and prehabilitation protocols present challenges in standardising the interventions. Further research is necessary to establish optimal prehabilitation strategies tailored to individual patient needs and to demonstrate their utility in terms of patient outcome.

Current Progress on Postoperative Cognitive Dysfunction: An Update

Postoperative cognitive dysfunction (POCD) represents a significant clinical concern, particularly among elderly surgical patients. It is characterized by a decline in cognitive performance, affecting memory, attention, coordination, orientation, verbal fluency, and executive function. This decline in cognitive abilities leads to longer hospital stays and increased mortality. This review provides a comprehensive overview of the current progress in understanding the relevant pathogenic factors, possible pathogenic mechanisms, diagnosing, prevention and treatment of POCD, as well as suggesting future research directions. It discusses neuronal damage, susceptible genes, central cholinergic system, central nervous system (CNS) inflammation, stress response and glucocorticoids, and oxidative stress in the development of POCD, aiming to uncover the pathological mechanism and develop effective treatment strategies for POCD.

Prehabilitation-A Simple Approach for Complex Patients: The Results of a Single-Center Study on Prehabilitation in Patients with Ovarian Cancer Before Cytoreductive Surgery

Background/Objectives: Prehabilitation is a low-cost, safe procedure with no side effects, and it may have a positive impact on postoperative outcomes. However, it is not widely implemented. Our study aimed to assess the impact of prehabilitation on postoperative outcomes in patients with ovarian cancer within the field of gynecological oncology. Methods: We analyzed 110 patients with ovarian cancer who participated in a prehabilitation program before cytoreductive surgery. Based on the results of a 6-min walk test (6MWT), patients were divided into two groups: Group A (patients who improved their 6MWT results) and Group B (patients who did not improve their 6MWT results). Results: Patients in Group A demonstrated better postoperative outcomes. The length of hospital stay was significantly shorter in Group A compared to Group B (median 7 [5, 9] vs. 9 [6, 17], p = 0.032). Group A also had a lower overall number of complications and also fewer complications, as summarized by the Clavien-Dindo classification, compared to Group B. Conclusions: Patient adherence to prehabilitation recommendations was adequate. Prehabilitation was associated with improved postoperative outcomes, including shorter hospital stays and fewer complications. These benefits were more pronounced with higher patient compliance with the prehabilitation program and improvements were recorded in preoperative physical capacity.

Prognostic Value of Hospital Frailty Risk Score and Clinical Outcomes in Critical Limb-Threatening Ischemia and End-Stage Kidney Disease

BACKGROUND

End-stage kidney disease (ESKD) is commonly associated with critical limb-threatening ischemia (CLTI) and frailty. Yet there are no specific tools to predict outcomes of CLTI in ESKD, particularly those that incorporate frailty. We aimed to assess the utility of the medical record-based Hospital Frailty Risk (HFR) score in predicting outcomes of CLTI in ESKD.

METHODS AND RESULTS

We identified patients with ESKD diagnosed with CLTI from the US Renal Data System from 2015 to 2018. These patients were categorized into 3 frailty risk groups on the basis of their HFR scores: low (<5), intermediate (5-10), high-risk (>10), and on the basis of whether they underwent revascularization (endovascular revascularization [ER]/surgical revascularization [SR]) or not (no revascularization). Primary outcomes of interest included in-hospital composite of death or major amputation and in-hospital death. We included 49 454 eligible patients, with ER/SR cohort including 19.8% (n=9777). A total of 88.4% (ER/SR) and 90.0% (no revascularization) were frail on the HFR scale. We found a nonlinear association between HFR score and in-hospital adverse outcomes. In both cohorts, intermediate and high-risk HFR scores were associated with greater risk of in-hospital death (high-risk, ER/SR: odds ratio, 2.7 [95% CI, 1.6-4.8]; P<0.0001; no revascularization: odds ratio, 7.8 [95% CI, 5.3-11.6]; P<0.01) and composite of in-hospital major amputation or death (high-risk, ER/SR: odds ratio, 2.4 [95% CI, 1.9-3.1]; P<0.0001; no revascularization: odds ratio, 1.7 [95% CI, 1.5-1.9]; P<0.0001).

CONCLUSIONS

The HFR score can predict risk of in-hospital death and composite of death or major amputation in patients with ESKD and CLTI. Further data are needed to determine the utility of the HFR score in this population.

Current developments in prehabilitation in urologic oncology

PURPOSE OF REVIEW

Prehabilitation describes interventions that are undertaken prior to a major surgical or medical intervention with the objective of improving functional capability with the goal of improving candidacy for therapy, bolstering one's ability to withstand treatment-associated toxicity, functional decline, and facilitating accelerated recovery. The objective of this review is to detail the key tenets of prehabilitation, synthesize contemporary advances in prehabilitation science within Urologic Oncology , and discuss key methodologic trial design considerations salient to future prehabilitation investigations.

RECENT FINDINGS

Contemporary prehabilitation clinical trials have primarily evaluated unimodal interventions aiming to improve functional capacity across the domains of physical exercise, nutrition, and cognition with heightened interest in evaluating multimodal interventions addressing two or more domains. Recent investigations have have demonstrated variable improvements in strength, balance, physical function, and quality of life with preoperative exercise. Although presurgical immunonutrition showed promise in other fields, initial results in uro-oncology have not demonstrated reductions in complications nor improvements in early survival. Emerging data supports the potential of multimodal prehabilitation programs to offer more comprehensive benefits, improving functional outcomes, reducing length of stay, and supporting improved recovery.

SUMMARY

To date, early prehabilitation studies in patients undergoing surgery for genitourinary malignancies have demonstrated variable ability to facilitate gains in functional capacity and perioperative outcomes. Key issues have arisen including the need to ensure that interventions are pragmatic, scalable, feasible, and acceptable in these populations that often also have a high prevalence of coincident multimorbidity, frailty, and mental health concerns that can increase risk of adverse outcomes after surgery. The integration of personalized prehabilitation strategies as extensions of perioperative enhanced recovery after surgery protocols, supportive care and survivorship paradigms offers of promise to further engage patients in their care, enhance patient resilience and outcomes, while reducing treatment burden in urologic oncology.