Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Preoperative cognitive performance and its association with postoperative complications in vascular surgery patients: A prospective study

BACKGROUND

Cognitive impairment affects nearly half of vascular surgery patients, but its association with postoperative outcomes remains poorly understood. This study explores the link between preoperative cognitive performance and postoperative complications, including postoperative delirium, in vascular surgery patients.

METHODS

A prospective cohort study was conducted on vascular surgery patients aged ≥65. Preoperative cognitive performance was assessed using the Montreal Cognitive Assessment, and postoperative complications were evaluated using the Comprehensive Complication Index. The association was analyzed through multivariable logistic regression.

RESULTS

Among 110 patients (18.2 ​% female, mean age 73.8 ​± ​5.7 years), cognitive impairment was evident in 48.2 ​%. Of the participants, 29 (26.3 ​%) experienced postoperative complications, among which 11 (10 ​%) experienced postoperative delirium. The adjusted odds ratio for the association between cognitive performance and postoperative complications was 1.19 (95 ​% CI 1.02-1.38; p ​= ​0.02).

CONCLUSION

Worse preoperative cognitive performance correlated with increased odds of postoperative complications and postoperative delirium in vascular surgery patients.

Effects of Chinese traditional five-element music intervention on postoperative delirium and sleep quality in elderly patients after non-cardiac surgery: a randomized controlled trial

BACKGROUND

Postoperative delirium (POD) is a common neurologic disorder among elderly patients after non-cardiac surgery, which leads to various negative outcomes. Sleep disorder is considered an important cause of POD. The objective of this study was to investigate whether the Chinese traditional five-element music intervention could reduce POD by improving sleep quality in elderly patients undergoing non-cardiac surgery.

METHODS

A total of 132 patients aged 65 to 90 years who underwent non-cardiac surgery were randomized to two groups: the intervention (n = 60) and the control group (n = 63). Patients in the intervention group were subjected to the Chinese traditional five-element music intervention during the perioperative, while patients in the control group had no music intervention. POD was evaluated using the Confusion Assessment Method (CAM) in the first 5 days after surgery. The Richards‒Campbell Sleep Questionnaire (RCSQ) was used to assess subjective sleep quality. The levels of nocturnal melatonin and cortisol in saliva were measured on the preoperative and the first 2 postoperative days.

RESULTS

The incidence of POD within 5 days was 27.0% in the control group and 11.7% in the intervention group. Preoperative PSQI and MMSE scores were associated with POD. The RCSQ scores on the first postoperative day were significantly decreased in the two groups compared to the preoperative day. Compared to the control group, the RCSQ scores showed a significant improvement in the intervention group on the first postoperative day. Compared to the control group, the level of saliva melatonin in the intervention group showed a significant increase on the first postoperative day. However, there was no statistical difference in cortisol levels between the two groups.

CONCLUSIONS

Chinese traditional five-element music intervention decreased the incidence of POD in elderly patients who underwent noncardiac surgery via improving sleep quality, which may be associated with increased levels of melatonin.

Relationships between muscle strength, lung function, and cognitive function in Chinese middle-aged and older adults: A study based on the China health and retirement longitudinal study (CHARLS)

OBJECTIVE

As the population ages, concerns about cognitive decline have become increasingly relevant in medical consultations. This study aims to analyze the interaction between muscle strength, lung function, and cognitive function in Chinese middle-aged and older adults, providing a theoretical basis for better prevention of cognitive decline.

METHODS

This study used data from the China Health and Retirement Longitudinal Study (CHARLS) wave 3, including 13 716 participants aged 45 years or older. Cognitive function was assessed through two dimensions, resulting in a total score ranging from 0 to 31 points, with higher scores indicating better cognitive function. Muscle strength was measured using normalized grip strength and chair-standing time, while lung function was evaluated using peak expiratory flow (PEF).

RESULTS

Total cognitive function scores exhibited significant correlations with grip strength, chair-standing time, and PEF. Muscle strength and lung function demonstrated significant associations with cognitive function, with lung function emerging as a notable mediating factor. This relationship persisted even after adjusting for potential confounding variables. Specifically, PEF played a substantial mediating role in linking grip strength to cognitive function scores (estimated indirect effect = 0.0132, boot-strapped standard error = 0.0015, boot-strapped standard 95% confidence interval = 0.0104, 0.0162). Additionally, PEF served as a significant mediator in the association between chair-standing time and cognitive function scores (estimated indirect effect = -0.0204, boot-strapped standard error = 0.0023, boot-strapped standard 95% confidence interval = -0.0251, -0.0159).

CONCLUSION

The study highlights the importance of addressing declines in muscle strength and lung function to identify risk factors associated with cognitive function. Understanding these relationships can provide insights into potential pathways linking these variables and may aid in better prevention of cognitive decline. Further long-term longitudinal cohort studies are needed to explore the causality between these factors.

The diagnostic accuracy of the Mini-Cog screening tool for the detection of cognitive impairment-A systematic review and meta-analysis

BACKGROUND

The Mini-Cog is a rapid screening tool that can be administered to older adults to detect cognitive impairment (CI); however, the accuracy of the Mini-Cog to detect CI for older patients in various healthcare settings is unclear.

OBJECTIVES

To evaluate the diagnostic accuracy of the Mini-Cog to screen for cognitive impairment in older patients across different healthcare settings.

METHODS/DESIGN

We searched nine electronic databases (including MEDLINE, Embase) from inception to January 2023. We included studies with patients ≥60 years old undergoing screening for cognitive impairment using the Mini-Cog across all healthcare settings. A cut-off of ≤ 2/5 was used to classify dementia, mild cognitive impairment (MCI), and cognitive impairment (defined as either MCI or dementia) across various settings. The diagnostic accuracy of the Mini-Cog was assessed against gold standard references such as the Diagnostic and Statistical Manual of Mental Disorders (DSM). A bivariate random-effects model was used to estimate accuracy and diagnostic ability. The risk of bias was assessed using QUADAS-2 criteria.

RESULTS

The systematic search resulted in 4,265 articles and 14 studies were included for analysis. To detect dementia (six studies, n = 4772), the Mini-Cog showed 76% sensitivity and 83% specificity. To detect MCI (two studies, n = 270), it showed 84% sensitivity and 79% specificity. To detect CI (eight studies, n = 2152), it had 67% sensitivity and 83% specificity. In the primary care setting, to detect either MCI, dementia, or CI (eight studies, n = 5620), the Mini-Cog demonstrated 73% sensitivity and 84% specificity. Within the secondary care setting (seven studies, n = 1499), the Mini-Cog to detect MCI, dementia or CI demonstrated 73% sensitivity and 76% specificity. A high or unclear risk of bias persisted in the patient selection and timing domain.

CONCLUSIONS

The Mini-Cog is a quick and freely available screening tool and has high sensitivity and specificity to screen for CI in older adults across various healthcare settings. It is a practical screening tool for use in time-sensitive and resource-limited healthcare settings.

Preoperative Management of the Adult Oncology Patient

Anesthesiologists are experiencing first-hand the aging population, given older patients more frequently presenting for surgery, often with geriatric syndromes influencing their anesthetic management. The overall incidence and health burden of cancer morbidity and mortality are also rapidly increasing worldwide. This growth in the cancer population, along with the associated risk factors and comorbidities often accompanying a cancer diagnosis, underscores the need for anesthesiologists to become well versed in the preoperative evaluation and management of the adult patient with cancer. This article will focus on the unique challenges and opportunities for the anesthesiologist caring for the adult oncology patient presenting for surgery.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Preoperative mild cognitive impairment as a risk factor of postoperative cognitive dysfunction in elderly patients undergoing spine surgery

Introduction

Any persistent degree of cognitive impairment in older adults is a concern as it can progress to dementia. This study aimed to determine the incidence and risk factors for early postoperative cognitive dysfunction (POCD) in elderly patients undergoing spine surgery.

Methods

Patients were enrolled from a previous prospective observational study after screening for normal cognitive function using the Mini Mental State Examination (MMSE). Cognitive function was evaluated before surgery and at 1 week, month, and year post-surgery using MMSE and Montreal Cognitive Assessment scores (MoCA). Mild cognitive impairment (MCI) was determined using the MoCA scores adjusted for age. POCD was defined as a drop of three or more points on the MMSE 1 week post-surgery. Multivariate logistic analysis was performed to identify POCD risk factors.

Results

A total of 427 patients were included. Eighty-five (20%) had pre-existing MCI. The MCI group showed lower MoCA scores at each time point (baseline, 1 week after surgery, 1 month after surgery, 1 year after surgery) compared to the non-MCI group. Those in the MCI group had a higher rate of admission to intensive care unit after surgery, postoperative delirium, and POCD 1 week post-surgery, than those in the non-MCI group (16.5% vs. 6.7%, p = 0.008; 27.1% vs. 15.8%, p = 0.024; and 18.8% vs. 8.2%, p < 0.001, respectively). Among them, 10.3% were assessed for POCD on postoperative day 7 and self-reported poor social roles and physical functioning 1 week postoperatively.

Conclusion

Preoperative MCI was seen in ~20% of surgical patients aged >70 years. POCD was seen in ~20% of patients with pre-existing MCI, and ~ 10% of those without. Benzodiazepine use, significant comorbidities, pre-existing MCI, and depressive tendencies were risk factors for POCD.

Effect of percutaneous cerebral oximetry-guided anaesthetic management on postoperative delirium in older adults undergoing off-pump coronary artery bypass grafting: study protocol for a single-centre prospective randomised controlled trial in a tertiary academic hospital in China

INTRODUCTION

Postoperative delirium is a prominent and clinically important complication in older adults after coronary artery bypass grafting (CABG) surgery, resulting in prolonged hospital stay, long-term cognitive impairment and increased morbidity and mortality. Many studies have shown that cerebral desaturation is associated with increased risk of postoperative delirium during on-pump cardiac surgery. However, few studies have focused on the effect of optimising regional cerebral oxygen saturation (rSO2) on postoperative delirium during off-pump CABG. The purpose of this study is to investigate whether intraoperative anaesthetic management based on percutaneous cerebral oximetry monitoring decreases the incidence of postoperative delirium in older adults undergoing off-pump CABG.

METHODS

This single-centre randomised controlled trial will randomly assign 200 patients to the intervention group or the control group at a ratio of 1:1. The patients in the intervention group will be observed by percutaneous cerebral oximetry monitoring that the desaturation (a drop of more than 20% from baseline value or rSO2 less than 55% for >60 consecutive seconds at either probe) during the procedure triggered the intervention strategies, while the cerebral oximetry data of the control group will be hidden from the clinical team and patients will be anaesthetised by the usual anaesthetic management. The primary outcome will be the incidence of postoperative delirium during the first 7 days after off-pump CABG. Delirium will be comprehensively evaluated by the combination of the Richmond Agitation Sedation Scale and the Confusion Assessment Method for the intensive care unit. The secondary outcomes will include the incidence of postoperative acute kidney injury and myocardial infarction during the hospital stay, as well as the intensive care unit and hospital length of stay.

ETHICS AND DISSEMINATION

This study was approved by the Ethics Committee of the Chinese Academy of Medical Sciences, Fuwai Hospital (No 2022-1824). Written informed consent will be obtained from each patient or their legal representatives before enrolment. The results of this trial will be published in an international peer-reviewed scientific journal.

TRIAL REGISTRATION NUMBER

ChiCTR2300068537.

Association between the neutrophil-to-lymphocyte ratio and cognitive impairment: a meta-analysis of observational studies

Background

Systemic inflammation is one of the underlying mechanisms of cognitive impairment. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a systemic inflammation indicator. This meta-analysis aimed to evaluate the association between high NLR and cognitive impairment (CI) risk.

Method

A comprehensive systematic search was conducted to identify eligible studies published until May 30, 2023. The reference group comprised patients with the lowest NLR level, whereas the exposure group comprised those with the highest NLR level. The main outcome was to examine the relationship between NLR and CI risk. The secondary outcome included the association between patient characteristics or comorbidities and CI risk.

Results

This meta-analysis included 11 studies published between 2018 and 2023, involving 10,357 patients. Patients with CI had a higher NLR than those without (mean difference=0.35, 95% confidence interval [CI]: 0.26-0.44, p < 00001, I2 = 86%). Consistently, pooled results revealed an association between high NLR and CI risk (odds ratio [OR]=2.53, 95% CI:1.67-3.82, p<0.0001, I2 = 84%). Furthermore, aging (mean difference =4.31 years, 95% CI:2.83-5.8, p < 0.00001, I2 = 92%), diabetes (OR=1.59, 95% CI:1.35-1.88, p < 0.00001, I2 = 66%), and hypertension (OR=1.36, 95% CI:1.19-1.57, p < 0.00001, I2 = 0%) were significant risk factors for CI. However, no significant associations were observed between CI and male gender (OR = 0.84, 95% CI:0.64-1.11, p = 0.22, I2 = 81%), body mass index (mean = -0.32 kg/m2, 95% CI: -0.82, 0.18, p = 0.2, I2 = 82%), alcohol consumption (OR = 1.11, 95% CI:0.95-1.3, p = 1.35, I2 = 0%), and smoking (OR = 0.99, 95% CI:0.87-1.13, p = 0.86, I2 = 0%). Meta-regression found that diabetes and hypertension, but not age, significantly moderated the association between NLR and CI.

Conclusion

This meta-analysis showed a significant association between high NLR and increased CI risk. Moreover, meta-regression identified diabetes and hypertension, but not age, as significant moderating factors in the relationship between NLR and CI. To validate and strengthen these findings, further large-scale studies are required.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023430384, identifier CRD42023430384.

Cataract Phacoemulsification in People with Dementia: Characterization and Outcomes

PURPOSE

To characterize cataract surgery in people with dementia (PWD) using a cataract surgery outcomes database.

METHODS

Demographics, medical and ocular history, surgical characteristics, and postoperative measures were analyzed for differences between PWD and non-PWD cohorts. Patient-level data were analyzed with Fisher's Exact Test, and eye-level data were analyzed with logistic regression using generalized estimating equations to account for correlation of eyes from the same individual.

RESULTS

507 eyes from 296 PWD were identified using appropriate ICD codes and cross-referenced to a cataract surgery outcomes database containing 12,949 eyes from 7,853 patients who underwent cataract phacoemulsification at a single center between January 2014 and October 2019. PWD were older (p < .001), had shorter duration cataract surgeries (p = .006), and were more likely to have mature cataract (p = .017). The rate of general anesthesia was higher in PWD (p = .005). There were no differences in complication rates between PWD and non-PWD cohorts. Both preoperative best corrected LogMAR distance visual acuity (CDVA) (p < .001) and postoperative CDVA (p < .001) were worse in PWD. CDVA significantly improved in both groups (p < .001); however, the average magnitude of improvement in CDVA was not significantly different between groups (p = .169).

CONCLUSIONS

PWD present for cataract surgery at a later age and were more likely to have mature cataracts and general anesthesia, but did not have higher rates of complication, and showed significant improvement in CDVA following surgery. These findings should be encouraging to PWD undergoing counseling for cataract surgery, and for the potential for improved function in PWD.

Development of a Brief Cognitive Screening Tool for Predicting Postoperative Delirium in Patients with Parkinson's Disease: A Secondary Analysis

Background

A simple, rapid, and effective cognitive screening test appropriate for fast-paced settings with limited resources and staff is essential, especially preoperatively. This study aimed to develop and validate the short versions of Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) for predicting postoperative delirium (POD) in patients with Parkinson's disease (PD) who were scheduled for surgery.

Methods

The current study was a secondary analysis of data collected from 128 inpatients scheduled for deep brain stimulation of the subthalamic nuclei (STN-DBS) lasting >60 min, at Tsinghua University Yuquan Hospital, China. Preoperative cognitive screening was performed during the preoperative visit using the MMSE and MoCA. The optimal MMSE and MoCA cut-off scores for detecting PD-MCI was 27 and 23 respectively. The POD was assessed twice a day on the first postoperative day until discharge by the confusion assessment method. The backward conditional logistic regression analysis was used to organize the reduced versions of the MMSE or MoCA. Also, the areas under the receiver operating characteristic curves (AUCs) were examined using the DeLong test.

Results

125/128 PD patients were included in the analysis, and 27 (21.6%) developed POD. The MMSE reduced version (orientation to time, attention and calculation, and comprehension) demonstrated performance similar to the original MMSE in predicting POD (z=0.820, p=0.412). The AUC of the original MoCA and the short MoCA (visuospatial and executive attention and orientation) were 0.808 and 0.826, respectively. There was no significantly difference in the AUC values between the tests (z=0.561, p=0.575).

Conclusion

Our simplified MMSE and MoCA could be efficiently used to identify patients at risk for POD. Also, short cognitive tests could be considered while predicting POD in fast-paced preoperative settings with limited resources and staff.

Prevalence of preoperative cognitive impairment among elderly thoracic surgery patients and association with postoperative delirium: a prospective observational study

Background

Preoperative cognitive impairment (PCI) may increase the incidence of postoperative delirium (POD), yet screening for cognitive impairment is rarely performed. This study hypothesized that Mini-Cog for preoperative cognitive impairment screening predicts postoperative delirium.

Methods

The prospective observational study recruited 153 elderly patients presenting for elective thoracic surgery. Cognitive function of these patients was screened using Mini-Cog preoperatively. We considered that patients with Mini-Cog scores ≤ 3 had cognitive impairment. Delirium was assessed using the Short CAM scale on postoperative days 1-5.

Results

Of the 153 participants, 54 (35.3%) were assigned to the PCI group, and 99 (64.7%) were assigned to the Normal group. Place of residence, education level, and history of hypertension were significantly different between the two groups (P < 0.05). 51 (33.3%) patients developed POD. Multifactorial analysis revealed that PCI (OR = 2.37, P = 0.028), older age (OR = 1.13, P = 0.009), ASA grade III (OR = 2.75, P = 0.012), and longer duration of anesthesia (OR = 1.01, P = 0.007) were associated with POD.

Conclusion

Preoperative cognitive impairment is strongly associated with POD. Mini-Cog could be recommended for screening PCI.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05798767.

[Mobile everyday-life digital technologies for the prevention of Alzheimer's dementia: cognitive health and cognitive safety]

It is generally accepted that the treatment of Alzheimer's disease should be flanked by preventive measures for risk reduction in order to maintain cognitive functions for as long as possible; however, the research and development of treatment concepts are both faced with challenges. The preventive risk reduction necessitates a high level of coordination of neurology and psychiatry with other disciplines. Also, patients must develop a high level of health competence and summon up self-motivation and adherence. This concept article deals with the question of how mobile everyday-life digital technologies can help to address these challenges. The core prerequisite is the interdisciplinary coordinated structuring of prevention with the focus on cognitive health and cognitive safety. Cognitive health relates to a reduction of risk factors associated with lifestyle. Cognitive safety concerns the avoidance of iatrogenic side effects on cognitive functions. Digital technologies that are relevant in this context are mobile apps based on smartphones or tablets for everyday-life and high-frequency recording of cognitive functions, apps that can coach the implementation of lifestyle changes as companion technologies, apps that can assist in the reduction of iatrogenic risks and those that can improve the health competence of patients and relatives. The state of development of such medical products is at different stages of progress. Therefore, this concept article does not provide a review of existing products but rather deals with the fundamental interplay of potential solutions in the prevention of Alzheimer dementia in the areas of cognitive health and cognitive safety.

Intergenerational Perioperative Neurocognitive Disorder

Accelerated neurocognitive decline after general anesthesia/surgery, also known as perioperative neurocognitive disorder (PND), is a widely recognized public health problem that may affect millions of patients each year. Advanced age, with its increasing prevalence of heightened stress, inflammation, and neurodegenerative alterations, is a consistent contributing factor to the development of PND. Although a strong homeostatic reserve in young adults makes them more resilient to PND, animal data suggest that young adults with pathophysiological conditions characterized by excessive stress and inflammation may be vulnerable to PND, and this altered phenotype may be passed to future offspring (intergenerational PND). The purpose of this narrative review of data in the literature and the authors' own experimental findings in rodents is to draw attention to the possibility of intergenerational PND, a new phenomenon which, if confirmed in humans, may unravel a big new population that may be affected by parental PND. In particular, we discuss the roles of stress, inflammation, and epigenetic alterations in the development of PND. We also discuss experimental findings that demonstrate the effects of surgery, traumatic brain injury, and the general anesthetic sevoflurane that interact to induce persistent dysregulation of the stress response system, inflammation markers, and behavior in young adult male rats and in their future offspring who have neither trauma nor anesthetic exposure (i.e., an animal model of intergenerational PND).

[Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies]

Benefit of a Geriatric Evaluation before Operations, Interventions and Oncological Therapies Abstract: Older patients face an increased risk of complications and adverse outcomes during and after operations, interventions, and intense oncological therapies. At the same time, this patient group should not be excluded per se from potentially beneficial medical procedures based on chronological age alone. The timely identification of geriatric syndromes and increased vulnerability by means of comprehensive geriatric assessment is becoming increasingly important and is already recommended in the guidelines of professional societies of several medical disciplines. Nonetheless, the geriatric assessment should ideally be followed by proactive co-management in the sense of integrated care. The establishment of interdisciplinary and integrated care pathways for older hospital patients can contribute to significantly improved treatment outcomes. In addition to better patient-related outcomes and rising quality indicators, this approach may also offer positive health economic effects.

Prevalence of unpaid caregiving, pain, and depression in older seriously ill patients undergoing elective surgery

INTRODUCTION

Serious illness is a life-limiting condition negatively impacting daily function, quality of life, or excessively straining caregivers. Over 1 million older seriously ill adults undergo major surgery annually, and national guidelines recommend that palliative care be available to all seriously ill patients. However, the palliative care needs of elective surgical patients are incompletely described. Understanding baseline caregiving needs and symptom burden among seriously ill older surgical patients could inform interventions to improve outcomes.

METHODS

Using Health and Retirement Study data (2008-2018) linked to Medicare claims, we identified patients ≥66 years who met an established serious illness definition from administrative data and underwent major elective surgery using Agency for Healthcare Research and Quality (AHRQ) criteria. Descriptive analyses were performed for preoperative patient characteristics, including: unpaid caregiving (no or yes); pain (none/mild or moderate/severe); and depression (no, CES-D < 3, or yes, CES-D ≥ 3). Multivariable regression was performed to examine the association between unpaid caregiving, pain, depression, and in-hospital outcomes, including hospital days (days admitted between discharge date and one-year post-discharge), in-hospital complications (no or yes), and discharge destination (home or non-home).

RESULTS

Of the 1343 patients, 55.0% were female and 81.6% were non-Hispanic White. Mean age was 78.0 (SD 6.8); 86.9% had ≥2 comorbidities. Before admission, 27.3% of patients received unpaid caregiving. Pre-admission pain and depression were 42.6% and 32.8%, respectively. Baseline depression was significantly associated with non-home discharge (OR 1.6, 95% CI 1.2-2.1, p = 0.003), while baseline pain and unpaid caregiving needs were not associated with in-hospital or post-acute outcomes in multivariable analysis.

CONCLUSIONS

Prior to elective surgery, older adults with serious illnesses have high unpaid caregiving needs and a prevalence of pain and depression. Baseline depression alone was associated with discharge destinations. These findings highlight opportunities for targeted palliative care interventions throughout the surgical encounter.

A randomised controlled trial of dexmedetomidine for delirium in adults undergoing heart valve surgery

Dexmedetomidine might reduce delirium after cardiac surgery. We allocated 326 participants to an infusion of dexmedetomidine at a rate of 0.6 μg kg^-1 for 10 min and then at 0.4 μg.kg^-1 .h^-1 until the end of surgery; 326 control participants received comparable volumes of saline. We detected delirium in 98/652 (15%) participants during the first seven postoperative days: 47/326 after dexmedetomidine vs. 51/326 after placebo, p = 0.62, adjusted relative risk (95%CI) 0.86 (0.56-1.33), p = 0.51. Postoperative renal impairment (Kidney Disease Improving Global Outcomes stages 1, 2 and 3) was detected in 46, 9 and 2 participants after dexmedetomidine and 25, 7 and 4 control participants, p = 0.040. Intra-operative dexmedetomidine infusion did not reduce the incidence of delirium after cardiac valve surgery but might impair renal function.

Prevalence of pre-operative undiagnosed cognitive impairment and its association with handgrip strength, oral hygiene, and nutritional status in older elective surgical patients in Japan

PURPOSE

Preoperative cognitive impairment is a significant factor influencing post-operative delirium. We have been performing routine pre-operative comprehensive assessments, including evaluation of cognitive function, handgrip strength, oral hygiene, and nutritional status, in patients aged ≥ 65 years since April 2021. This study aimed to examine the completion rate of pre-operative comprehensive assessment and assess the prevalence of pre-operative undiagnosed cognitive impairment.

METHODS

In this prospective observational study including patients aged ≥ 65 years scheduled for elective surgery with general or regional anesthesia, cognitive impairment was defined as a Mini-Cog score ≤ 2, and its associations with handgrip strength, oral hygiene, and nutritional status were evaluated. Oral hygiene and nutritional status were assessed using an oral frailty self-checklist and the Mini Nutritional Assessment-Short Form, respectively. The incidence of pre-operative undiagnosed cognitive impairment was estimated, and its associated factors were explored with multiple logistic regression.

RESULTS

Among 331 eligible patients, the completion rate was 97.7% (305/312). The mean age was 74.8 years, and 13.1% (40/305) (95% confidence interval [CI], 9.7-17.3%) of the patients had pre-operative undiagnosed cognitive impairment. Multiple logistic regression revealed that handgrip strength (odds ratio [OR] = 0.94, 95%CI = 0.89-0.99) and oral frailty self-checklist score (OR = 1.19, 95%CI = 1.02-1.40) were associated with pre-operative undiagnosed cognitive impairment, while the Mini Nutritional Assessment-Short Form score was not significantly associated (OR = 0.97, 95%CI = 0.82-1.14).

CONCLUSIONS

Preoperative comprehensive assessment was feasible. The prevalence of pre-operative undiagnosed cognitive impairment was 13%, and poor handgrip strength and worse oral hygiene were significantly associated factors.

Postoperative Outcomes in Elderly Patients Undergoing Cardiac Surgery With Preoperative Cognitive Impairment: A Systematic Review and Meta-Analysis

BACKGROUND

Older patients with preoperative cognitive impairment are at risk for increased postoperative complications after noncardiac surgery. This systematic review and meta-analysis aimed to determine the association between preoperative cognitive impairment and dementia and postoperative outcomes in older surgical patients after cardiac surgery.

METHODS

Eight electronic databases were searched from inception to January 4, 2022. Inclusion criteria were cardiac surgery patients ≥60 years of age; preoperative cognitive impairment; ≥1 postoperative complication reported; comparator group with no preoperative cognitive impairment; and written in English. Using a random-effects model, we calculated effect sizes as odds ratio (OR) and standardized mean differences (SMDs). Risk of random error was assessed by applying trial sequential analysis.

RESULTS

Sixteen studies (62,179 patients) were included. Preoperative cognitive impairment was associated with increased risk of delirium in older patients after cardiac surgery (70.0% vs 20.5%; OR, 8.35; 95% confidence interval [CI], 4.25-16.38; I2, 0%; P < .00001). Cognitive impairment was associated with increased hospital length of stay (LOS; SMD, 0.36; 95% CI, 0.20-0.51; I2, 22%; P < .00001) and intensive care unit (ICU) LOS (SMD, 0.39; 95% CI, 0.09-0.68; I2, 70%; P = .01). No significant association was seen for 30-day mortality (1.7% vs 1.1%; OR, 2.58; 95% CI, 0.64-10.44; I2, 55%; P = .18).

CONCLUSIONS

In older patients undergoing cardiac surgery, cognitive impairment was associated with an 8-fold increased risk of delirium, a 5% increase in absolute risk of major postoperative bleeding, and an increase in hospital and ICU LOS by approximately 0.4 days. Further research on the feasibility of implementing routine neurocognitive testing is warranted.