Agreement Between the Mini-Cog in the Preoperative Clinic and on the Day of Surgery and Association With Postanesthesia Care Unit Delirium: A Cohort Study of Cognitive Screening in Older Adults

Predictive ability of Mini-Cog for postoperative delirium: A systematic review and meta-analysis

AIM

This study aims to determine the predictive value of the preoperative Mini-Cognitive Assessment Instrument (Mini-Cog) for postoperative delirium (POD), a significant complication in older surgical patients. Given its widespread recommendation despite unclear predictive utility, we will conduct the first meta-analysis to synthesize the available evidence.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines. Electronic databases (Medline, CINAHL, Cochrane Library, and Web of Science) were searched from inception to May 2024. Studies evaluating the association between preoperative Mini-Cog scores and POD were included. Two independent reviewers performed study selection and data extraction. The methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. Random-effects models were used to calculate pooled odds ratios (ORs), sensitivity, and specificity. Sensitivity analyses were performed based on standardized cutoff values and POD assessment methods.

RESULTS

Sixteen studies involving 4980 patients were included. Participants' mean/median ages ranged from 70 to 80 years, and the percentage of patients scoring below the Mini-Cog cutoff varied from 12.5% to 60.5%. Low Mini-Cog scores were significantly associated with increased POD risk (OR = 3.79; 95% confidence interval [CI] = 2.81-5.12; I2 = 57%). The Mini-Cog demonstrated a pooled specificity of 0.80 and sensitivity of 0.50 for POD prediction. Sensitivity analysis of studies using standardized cutoffs (<3) and validated POD assessment tools yielded an OR of 3.40 (95% CI = 2.56-4.53). Half of the included studies showed a low risk of bias across all QUADAS-2 domains. Publication bias assessment using funnel plots and Egger's test showed no significant bias.

CONCLUSIONS

The Mini-Cog shows moderate predictive ability for POD, with high specificity but limited sensitivity. While it may be valuable as part of comprehensive preoperative assessment, its moderate sensitivity suggests it should not be used as the sole predictor. The variability in surgical populations and assessment methods highlights the need for standardization. Future research should focus on establishing consistent methodologies and exploring the Mini-Cog's efficacy in specific surgical populations to enhance its clinical utility in POD risk stratification. Geriatr Gerontol Int 2025; ••: ••-••.

Association Between Cognitive Impairment and Poor Oral Function in Community-Dwelling Older People: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

The population of Japan has a high life expectancy, but there is room for improvement in terms of the country's healthy life expectancy. The long period of care dependency among Japan's elderly is also a major economic health challenge. Dementia is a major factor in the need for care, and its prevention is a crucial and urgent challenge. There are recent reports of a possible association between changes in oral function and cognitive impairment, but the details of this association remain unclear. To clarify the relationship between poor oral function and cognitive impairment, we conducted an exploratory investigation using a cognitive function assessment (Mini-Cog) administered in a large-scale study and its relevance to oral function.

METHODS

The study population was 678 community-dwelling individuals aged ≥65 years living in Tarumizu city, Japan, in 2019. Cognitive function was assessed using the Mini-Cog test, and the oral survey was a modification of the content of the Oral Hypofunction Examination as defined by the Japanese Society of Gerodontology.

RESULTS

The participants' median age was 73 years. The oral function results revealed median scores below the oral hypofunction criterion for occlusal force, tongue pressure, oral diadochokinesis, and swallowing function. The results of a binomial logistic regression analysis indicated that tongue-lip motor function was independently associated with oral function in relation to cognitive impairment.

CONCLUSIONS

The oral function associated with cognitive impairment in this study was tongue-lip motor function. Aiming to improve this function may prevent the exacerbation of cognitive impairment.

Ability of clock drawing errors on Mini-Cog test to predict development of delirium after major urological cancer surgery

Background

This study aimed to evaluate the impact of the clock drawing test (CDT) on postoperative delirium and compare the abilities of the mini-cognitive (Mini-Cog) test and the CDT for predicting postoperative delirium after major urological cancer surgery.

Materials and methods

In this single-center retrospective observational study, we collected the medical records of patients who underwent major urologic cancer surgery and preoperative cognitive screening based on the Mini-Cog test consisting of the CDT and the 3-word recall task at our department in 2020-2021 (n = 387). Univariate and multivariate logistic regression analyses were used to identify the clinical risk factors for postoperative delirium. We also compared the ability of the CDT alone and the Mini-Cog test consisting of the CDT and 3-word recall task to predict postoperative delirium.

Results

A total of 117 patients (30%) had abnormal CDT results. Postoperative delirium occurred in 29 patients (7%). On multivariate analysis, American Society of Anesthesiologists physical status ≥3 (odds ratio [OR], 5.0; p = 0.01), abnormal CDT (OR, 4.8; p < 0.001), preoperative benzodiazepine use (OR, 4.9; p < 0.001), and operative time ≥237 minutes (OR, 3.0; p = 0.01) were independent risk factors for postoperative delirium. The area under the curve for predicting postoperative delirium was 0.709 for CDT alone and 0.743 for the Mini-Cog test. No significant intergroup difference was observed (p = 0.43).

Conclusions

The CDT served as a formal but simple tool with adequate predictive power to identify the risk of postoperative delirium among patients undergoing major urological cancer surgery. Effective screening using the CDT might help provide optimal urological care for older patients.

Perioperative Considerations in Older Kidney and Liver Transplant Recipients: A Review

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

The effect of two different modes of anaesthesia maintenance on postoperative delirium in elderly patient with low preoperative mini-cog score

BACKGROUND

Postoperative delirium is a common distressing symptom experienced following laparoscopic cholecystectomy. The study aimed to investigate the influence of a low preoperative Mini-Cog testing score and 2 different anesthesia methods: total intravenous anaesthesia (TIVA) versus sevoflurane, on postoperative delirium in elderly patients undergoing laparoscopic cholecystectomy.

METHODS

A total of 84 patients over 60 years old who underwent laparoscopic cholecystectomy between March 1and - October 1 2023 were included in the study. Patients with a Mini-Cog score of 0-2 were considered to have low and possibly impaired neurocognitive function. We invastigated the effects of preoperative Mini-Cog score and the two anesthesia methods used on the incidence of postoperative delirium.

RESULTS

The proportion of patients with low Mini-Cog score in the preoperative period was 17.9%. Sevoflurane and TIVA was used in 41 and 43 patients respectively. The incidence of postoperative delirium in patients with low preoperative Mini-Cog scores was 66.7% at postoperative 0 h and 33.3% at the 1st hours. Postoperative delirium was found to be statistically higher in patients with low Mini-cog scores than in those with negatively-screened for Mini-cog scores (p: 0.01-0.035). In patients using sevoflurane, the incidence of postoperative delirium was 26.8% and 24.4% at the 0 and 1st hours, respectively. This was found to be statistically higher than in patients receiving TIVA (p: 0.036 - 0.010).

CONCLUSION

Low Mini-Cog score was an indicator of a higher risk of early postoperative delirium. Sevoflurane is more likely to cause postoperative delirium than TIVA.

TRIAL REGISTRATION

The study was registered on ClinicalTrials.gov (Identifier: NCT06597812) .

Assessing cognitive impairment in home-dwelling Chinese elders aged 80+: a detailed survey of 13,000 participants focusing on demographic factors, social engagement, and disease prevalence

Introduction

Cognitive Impairment (CI) in the elderly, encompassing conditions ranging from Mild Cognitive Impairment (MCI) to dementia, represents a growing public health concern globally. This study aims to investigate the prevalence and correlates of CI among individuals aged 80 and above.

Methods

The study conducts 13,027 elderly individual's door-to-door surveys, followed by the cross-tabulation of analysis data, logistic regression analysis, and health condition assessments to examine various determinants of CI.

Results

The current study's key findings demonstrate sub-statical correlations between CI and various factors, including educational attainment, marital status, and gender. Pronounced differences are evident between urban and rural demographics. Furthermore, aspects of social engagement, notably communication proficiency and sensory capabilities, exhibit a strong association with CI. Logistic regression analysis highlights that residing in rural areas (Odds Ratio [OR] = 0.637) and being female (OR = 0.71) are linked to a decreased risk of CI. In contrast, behavioral and health-related variables present a complex picture. Specifically, aggressive behavior (Adjusted OR = 1.881) and symptoms of depression (Adjusted OR = 0.549) contrast with conditions such as asthma (OR= 2.857) and cerebral infarction (OR=1.348), which elevate the risk of CI. Intriguingly, hyperlipidemia (OR= 0.671) appears to confer a protective effect against CI.

Conclusion

The study highlights the complexity of factors affecting CI in the elderly, advocating for a comprehensive approach to understanding and managing cognitive health.

The Effect of Dexmedetomidine on the Mini-Cog Score and High-Mobility Group Box 1 Levels in Elderly Patients with Postoperative Neurocognitive Disorders Undergoing Orthopedic Surgery

Dexmedetomidine prevents postoperative cognitive dysfunction by inhibiting high-mobility group box 1 (HMGB1), which acts as an inflammatory marker. This study investigated the HMGB1 levels and the cognitive function using a Mini-Cog© score in elderly patients undergoing orthopedic surgery with dexmedetomidine infusion. In total, 128 patients aged ≥ 65 years were analyzed. The patients received saline in the control group and dexmedetomidine in the dexmedetomidine group until the end of surgery. Blood sampling and the Mini-Cog© test were performed before the surgery and on postoperative days 1 and 3. The primary outcomes were the effect of dexmedetomidine on the HMGB1 levels and the Mini-Cog© score in terms of postoperative cognitive function. The Mini-Cog© score over time differed significantly between the groups (p = 0.008), with an increase in the dexmedetomidine group. The postoperative HMGB1 levels increased over time in both groups; however, there was no significant difference between the groups (p = 0.969). The probability of perioperative neurocognitive disorders decreased by 0.48 times as the Mini-Cog© score on postoperative day 3 increased by 1 point. Intraoperative dexmedetomidine has shown an increase in the postoperative Mini-Cog© score. Thus, the Mini-Cog© score is a potential tool for evaluating cognitive function in elderly patients.

"The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition

Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.

Poor preoperative performance at Clock Drawing Test is associated with postoperative decline in olfaction in older patients: an observational pilot study

BACKGROUND

Decline in olfaction may occur after general anesthesia, but the exact incidence and underlying physiopathology remain scarcely investigated. Olfactory dysfunction arises with aging and is known to be linked to cognitive impairment. In this pilot study, we evaluated the incidence of immediate postoperative decline in olfaction and its association with a preoperative cognitive test, performance at Clock Drawing Test (CDT), in a group of older patients.

METHODS

This pilot study is a sub-analysis of a prospective observational study. Patients ≥ 65 years old and scheduled for elective non-cardiac surgery under sevoflurane-based anesthesia were enrolled. CDT was part of the preoperative evaluation. We assessed olfaction on the day before and the day after surgery (between 16 and 26 h postoperatively) using the Sniffin' Sticks 12-item identification test, which consists of pen-like devices displaying 12 different odors. Postoperative decline in olfaction was defined as a decrease of at least 1 standard deviation in the olfactory score.

RESULTS

We included a total of 93 patients, among whom 19 (20.4%) presented a postoperative decline in olfaction. The incidence of postoperative decline in olfaction was higher in the "CDT low-score" (score ≤ 5/8) group (11/34, 32.4%) than in the "CDT high-score" (score ≥ 6/8) group (8/58, 13.6%) (P = 0.030). Despite adjusting for confounding variables, CDT score remained independently associated with immediate postoperative decline in olfactory identification function (OR 0.67, 95% CI 0.48 to 0.94, P = 0.022).

CONCLUSIONS

Postoperative decline in olfaction occurred in 20.4% of older patients and was associated with poor preoperative performance at CDT.

TRIAL REGISTRATION

This study was retrospectively registered on https://clinicaltrials.gov/ under the NCT04700891 number (principal investigator: Victoria Van Regemorter), in December 2020.

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.

Preoperative Cognitive Impairment and Postoperative Delirium in Elderly Surgical Patients: A Retrospective Large Cohort Study (The CIPOD Study)

OBJECTIVE

To test the hypothesis that in surgical patients ≥70 years, preoperative cognitive impairment is independently associated with postoperative delirium.

BACKGROUND

Postoperative delirium is common among elderly surgical patients and is associated with longer hospitalization and significant morbidity. Some evidence suggest that baseline cognitive impairment is an important risk factor. Routine screening for both preoperative cognitive impairment and postoperative delirium is recommended for older surgical patients. As of 2019, we implemented such routine perioperative screening in all elective surgical patients ≥70 years.

METHODS

Retrospective single-center analysis of prospectively collected data between January and December 2020. All elective noncardiac surgical patients ≥70 years without pre-existing dementia were included. Postoperative delirium, defined as 4A's test score ≥4, was evaluated in the postanesthesia care unit and during the initial 2 postoperative days. Patients' electronic records were also reviewed for delirium symptoms and other adverse outcomes.

RESULTS

Of 1518 eligible patients, 1338 (88%) were screened preoperatively [mean (SD) age 77 (6) years], of whom 21% (n=279) had cognitive impairment (Mini-Cog score ≤2). Postoperative delirium occurred in 15% (199/1338). Patients with cognitive impairment had more postoperative delirium [30% vs. 11%, adjusted odds ratio (95% confidence interval) 3.3 (2.3-4.7)]. They also had a higher incidence of a composite of postoperative complications [20% vs. 12%, adjusted odds ratio: 1.8 (1.2-2.5)], and median 1-day longer hospital stay [median (interquartile range): 6 (3,12) vs. 5 (3,9) days].

CONCLUSIONS

One-fifth of elective surgical patients ≥70 years present to surgery with preoperative cognitive impairment. These patients are at increased risk of postoperative delirium and major adverse outcomes.

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.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

Importance

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

Objective

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

Evidence Review

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

Findings

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

Conclusions and Relevance

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Instruments to Identify Delirium in Patients Recovering From Anesthesia: A Scoping Review

PURPOSE

To identify the validated instruments used for screening and detecting postoperative delirium (POD) during Post Anesthesia Recovery (PAR) period, and the incidence and associated risk factors with POD.

DESIGN

A scoping review.

METHODS

The study search occurred in May 2021 in the PubMed, Embase, Scopus, CINAHL, Web of Science and LILACS databases. Primary studies that used validated instruments for screening and detecting POD in the PAR period were included.

FINDINGS

A total of 38 articles were included. The most used instruments were CAM-ICU, Nu-DESC, and RASS. The instruments that screened and detected delirium earliest were the Nu-DESC and CAM-ICU. POD incidence was up to 20% in more than half of the included studies. Cardiovascular comorbidities, chronic kidney disease, low functional reserve, chronic obstructive pulmonary disease and postoperative pain were among the primary risk factors.

CONCLUSION

The instrumentsshowing the greatest accuracy for screening and detecting POD in the PAR period were the Nu-DESC and CAM-ICU.

Potentially Inappropriate Medication Administration Is Associated With Adverse Postoperative Outcomes in Older Surgical Patients: A Retrospective Cohort Study

BACKGROUND

The American Geriatrics Society (AGS) Beers Criteria is an explicit list of potentially inappropriate medications (PIMs) best avoided in adults ≥65 years of age. Cognitively impaired and frail surgical patients often experience poor outcomes after surgery, but the impacts of PIMs on these patients are unclear. Our objective was to assess whether perioperative PIM administration was associated with poor outcomes in geriatric surgical patients. We then evaluated the association between PIM administration and postoperative outcomes in subgroups of patients who were frail or cognitively impaired.

METHODS

We performed a retrospective cohort study of patients ≥65 years of age who underwent elective inpatient surgery at a large academic medical center from February 2018 to January 2020. Edmonton Frail Scale and Mini-Cog screening tools were administered to all patients at their preoperative clinic visit. A Mini-Cog score of 0 to 2 was considered cognitive impairment, and frailty was defined by an Edmonton Frail Scale score of ≥8. Patients were divided into 2 groups depending on whether they received at least 1 PIM (PIM+), based on the 2019 AGS Beers Criteria, in the perioperative period or none (PIM-). We assessed the association of preoperative frailty, cognitive impairment, and perioperative PIM administration with the length of hospital stay and discharge disposition using multiple regression analyses adjusted for age, sex, ASA physical status, and intensive care unit (ICU) admission.

RESULTS

Of the 1627 included patients (mean age, 73.7 years), 69.3% (n = 1128) received at least 1 PIM. A total of 12.7% of patients were frail, and 11.1% of patients were cognitively impaired; 64% of the frail patients and 58% of the cognitively impaired patients received at least 1 PIM. Perioperative PIM administration was associated with longer hospital stay after surgery (PIM-, 3.56 ± 5.2 vs PIM+, 4.93 ± 5.66 days; P < .001; 95% confidence interval [CI], 0.360-0.546). Frail patients who received PIMs had an average length of stay (LOS) that was nearly 2 days longer than frail patients who did not receive PIMs (PIM-, 4.48 ± 5.04 vs PIM+, 6.33 ± 5.89 days; P = .02). Multiple regression analysis revealed no significant association between PIM administration and proportion of patients discharged to a care facility (PIM+, 26.3% vs PIM-, 28.7%; P = .87; 95% CI, -0.046 to 0.054).

CONCLUSIONS

Perioperative PIM administration was common in older surgical patients, including cognitively impaired and frail patients. PIM administration was associated with an increased hospital LOS, particularly in frail patients. There was no association found between PIM administration and discharge disposition.

Risk assessment of perioperative neurocognitive disorders, where are we now?

PURPOSE OF REVIEW

Perioperative neurocognitive disorders (PNDs) are among the most frequent complications after surgery and are associated with considerable morbidity and mortality. We analysed the recent literature regarding risk assessment of PND.

RECENT FINDINGS

Certain genetic variants of the cholinergic receptor muscarinic 2 and 4, as well as a marked degree of frailty but not the kind of anaesthesia (general or spinal) are associated with the risk to develop postoperative delirium (POD). Models predict POD with a discriminative power, for example, area under the receiver operating characteristics curve between 0.52 and 0.94.

SUMMARY

Advanced age as well as preexisting cognitive, functional and sensory deficits remain to be the main risk factors for the development of PND. Therefore, aged patients should be routinely examined for both preexisting and new developing deficits, as recommended in international guidelines. Appropriate tests should have a high discrimination rate, be feasible to be administered by staff that do not require excessive training, and only take a short time to be practical for a busy outpatient clinic. Models to predict PND, should be validated appropriately (and externally if possible) and should not contain a too large number of predictors to prevent overfitting of models.

The Mini-Cog: A simple screening tool for cognitive impairment useful in predicting the risk of delirium after major urological cancer surgery

AIM

The purpose of this study was to evaluate the impact of the mini-cognitive assessment instrument (Mini-Cog) on postoperative delirium after major urological cancer surgery.

METHODS

In this single-center retrospective observational study, medical records were collected for patients who underwent major urologic cancer surgery at our department between 2020 and 2021, and underwent preoperative cognitive screening based on the Mini-Cog test (n = 331). The probable cognitive impairment is defined as a Mini-Cog score of <3. Univariate and multivariate logistic regression analysis were used to identify the risk factors for postoperative delirium.

RESULTS

Patients with probable cognitive impairment were 60 (18%). Postoperative delirium occurred in 26 patients (8%). Using multivariate analysis, the Mini-Cog score of <3 (odds ratio [OR] = 12.7; P < 0.001), decline of instrumental activities of daily living (OR = 3.0; P = 0.04) and preoperative benzodiazepine use (OR = 8.3; P < 0.001) were independent risk factors for postoperative delirium. For predicting postoperative delirium, Mini-Cog score with a cutoff value of <3 granting sensitivity of 69.2%, specificity of 86.2%, positive predictive value of 30.0% and negative predictive value of 97.1%.

CONCLUSIONS

The Mini-Cog test is a simple screening tool with only two components (a delayed, three-word recall task and a clock drawing test): it is useful in identifying potential cases of cognitive decline and patients at risk for postoperative delirium along with other information routinely collected preoperatively. Effective screening using the Mini-Cog test opens the possibility to provide optimal urologic care for older patients Geriatr Gerontol Int 2022; 22: 319-324.

Does Preoperative Cognitive Optimization Improve Postoperative Outcomes in the Elderly?

Perioperative neurocognitive disorder (PND) is a growing concern, affecting several million elderly patients each year in the United States, but strategies for its effective prevention have not yet been established. Humeidan et al. recently demonstrated that preoperative brain exercise resulted in a decrease in postoperative delirium incidence in elderly surgical patients, suggesting the potential of presurgical cognitive optimization to improve postoperative cognitive outcomes. This brief review summarizes the current knowledge regarding preoperative cognitive optimization and highlights landmark studies, as well as current ongoing studies, as the field is rapidly growing. This review further discusses the benefit of cognitive training in non-surgical elderly populations and the role of cognitive training in patients with preexisting cognitive impairment or dementia. The review also examines preclinical evidence in support of cognitive training, which can facilitate understanding of brain plasticity and the pathophysiology of PND. The literature suggests positive impacts of presurgical cognitive optimization, but further studies are encouraged to establish effective cognitive training programs for elderly presurgical patients.

Perioperative frailty: lessons learned and future directions

PURPOSE OF REVIEW

As the surgical population ages, preoperative diagnosis and optimization of frailty becomes increasingly important. Various concepts are used to define frailty, and several tools have been validated for use in the perioperative period. This article reviews current conceptual frameworks of frailty, references current literature and provides a practical approach to the preoperative frailty assessment with a focus on potential interventions.

RECENT FINDINGS

A multipronged approach toward preoperative optimization should be used in patients with frailty syndrome. Oral protein supplementation and immunonutrition therapy can reduce complications in patients with malnutrition. Initiating a preoperative physical exercise regimen may mitigate frailty. Nonpharmacologic interventions to reduce preoperative anxiety and improve mood are effective, low-cost adjuncts associated with improvement in postoperative outcomes. Engaging in shared decision making is a critical component of the preoperative evaluation of frail patients.

SUMMARY

Emerging evidence suggests that frailty may be mitigated with patient-specific, multidimensional preoperative interventions, thus potentially improving postoperative outcomes in this vulnerable patient population.

Prevention of postoperative delirium through the avoidance of potentially inappropriate medications in a geriatric surgical patient

We demonstrate the utility of risk stratification for postoperative delirium in geriatric patients and show that postoperative delirium can be prevented in high-risk patients when potentially inappropriate medications (PIMs) (medications that are best avoided in older adults) are avoided. In this case, a 65-year-old woman underwent two debridement procedures with similar presurgical risk for postoperative delirium. There was no risk stratification or preoperative cognitive assessment in the first procedure, she received PIMs and developed postoperative delirium. In the second procedure, PIMs were intentionally avoided and postoperative delirium did not occur. This case supports recent recommendations from the European Society of Anaesthesiology, the American Society of Anesthesiologists and the American Geriatrics Society that providers assess a patient's cognitive function and delirium risk profile preoperatively to appropriately guide perioperative management.