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Kehler DS, Arora RC. Commentary: Does a “less is more” approach reduce delirium in patients undergoing coronary artery bypass grafting? J Thorac Cardiovasc Surg 2021; 161:1285-1286. [DOI: 10.1016/j.jtcvs.2019.10.131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 01/06/2023]
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Pajares MA, Margarit JA, García-Camacho C, García-Suarez J, Mateo E, Castaño M, López Forte C, López Menéndez J, Gómez M, Soto MJ, Veiras S, Martín E, Castaño B, López Palanca S, Gabaldón T, Acosta J, Fernández Cruz J, Fernández López AR, García M, Hernández Acuña C, Moreno J, Osseyran F, Vives M, Pradas C, Aguilar EM, Bel Mínguez AM, Bustamante-Munguira J, Gutiérrez E, Llorens R, Galán J, Blanco J, Vicente R. Guidelines for enhanced recovery after cardiac surgery. Consensus document of Spanish Societies of Anesthesia (SEDAR), Cardiovascular Surgery (SECCE) and Perfusionists (AEP). REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:183-231. [PMID: 33541733 DOI: 10.1016/j.redar.2020.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/03/2020] [Accepted: 11/09/2020] [Indexed: 01/28/2023]
Abstract
The ERAS guidelines are intended to identify, disseminate and promote the implementation of the best, scientific evidence-based actions to decrease variability in clinical practice. The implementation of these practices in the global clinical process will promote better outcomes and the shortening of hospital and critical care unit stays, thereby resulting in a reduction in costs and in greater efficiency. After completing a systematic review at each of the points of the perioperative process in cardiac surgery, recommendations have been developed based on the best scientific evidence currently available with the consensus of the scientific societies involved.
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Affiliation(s)
- M A Pajares
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España.
| | - J A Margarit
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - C García-Camacho
- Unidad de Perfusión del Servicio de Cirugía Cardiaca, Hospital Universitario Puerta del Mar,, Cádiz, España
| | - J García-Suarez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Puerta de Hierro, Madrid, España
| | - E Mateo
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - M Castaño
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - C López Forte
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J López Menéndez
- Servicio de Cirugía Cardiaca, Hospital Ramón y Cajal, Madrid, España
| | - M Gómez
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - M J Soto
- Unidad de Perfusión, Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - S Veiras
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | - E Martín
- Servicio de Cirugía Cardiaca, Complejo Asistencial Universitario de León, León, España
| | - B Castaño
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Complejo Hospitalario de Toledo, Toledo, España
| | - S López Palanca
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - T Gabaldón
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - J Acosta
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - J Fernández Cruz
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari de La Ribera, Valencia, España
| | - A R Fernández López
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Virgen Macarena, Sevilla, España
| | - M García
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - C Hernández Acuña
- Servicio de Cirugía Cardiaca, Hospital Universitari de La Ribera, Valencia, España
| | - J Moreno
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital General Universitario de Valencia, Valencia, España
| | - F Osseyran
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - M Vives
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - C Pradas
- Servicio de Cirugía Cardiaca, Hospital Universitari Dr. Josep Trueta, Girona, España
| | - E M Aguilar
- Servicio de Cirugía Cardiaca, Hospital Universitario 12 de Octubre, Madrid, España
| | - A M Bel Mínguez
- Servicio de Cirugía Cardiaca, Hospital Universitari i Politècnic La Fe, Valencia, España
| | - J Bustamante-Munguira
- Servicio de Cirugía Cardiaca, Hospital Clínico Universitario de Valladolid, Valladolid, España
| | - E Gutiérrez
- Servicio de Cirugía Cardiaca, Hospital Universitario Virgen del Rocío, Sevilla, España
| | - R Llorens
- Servicio de Cirugía Cardiovascular, Hospiten Rambla, Santa Cruz de Tenerife, España
| | - J Galán
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | - J Blanco
- Unidad de Perfusión, Servicio de Cirugía Cardiovascular, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - R Vicente
- Servicio de Anestesiología, Reanimación y Terapéutica del Dolor, Hospital Universitari i Politècnic La Fe, Valencia, España
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Li Z, Dawson E, Moodie J, Martin J, Bagur R, Cheng D, Kiaii B, Hashi A, Bi R, Yeschin M, John-Baptiste A. Measurement and prognosis of frail patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis. BMJ Open 2021; 11:e040459. [PMID: 33664067 PMCID: PMC7934784 DOI: 10.1136/bmjopen-2020-040459] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 12/09/2020] [Accepted: 12/22/2020] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Our objectives were to review the literature to identify frailty instruments in use for transcatheter aortic valve implantation (TAVI) recipients and synthesise prognostic data from these studies, in order to inform clinical management of frail patients undergoing TAVI. METHODS We systematically reviewed the literature published in 2006 or later. We included studies of patients with aortic stenosis, diagnosed as frail, who underwent a TAVI procedure that reported mortality or clinical outcomes. We categorised the frailty instruments and reported on the prevalence of frailty in each study. We summarised the frequency of clinical outcomes and pooled outcomes from multiple studies. We explored heterogeneity and performed subgroup analysis, where possible. We also used Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to assess the overall certainty of the estimates. RESULTS Of 49 included studies, 21 used single-dimension measures to assess frailty, 3 used administrative data-based measures, and 25 used multidimensional measures. Prevalence of frailty ranged from 5.67% to 90.07%. Albumin was the most commonly used single-dimension frailty measure and the Fried or modified Fried phenotype were the most commonly used multidimensional measures. Meta-analyses of studies that used either the Fried or modified Fried phenotype showed a 30-day mortality of 7.86% (95% CI 5.20% to 11.70%) and a 1-year mortality of 26.91% (95% CI 21.50% to 33.11%). The GRADE system suggests very low certainty of the respective estimates. CONCLUSIONS Frailty instruments varied across studies, leading to a wide range of frailty prevalence estimates for TAVI recipients and substantial heterogeneity. The results provide clinicians, patients and healthcare administrators, with potentially useful information on the prognosis of frail patients undergoing TAVI. This review highlights the need for standardisation of frailty measurement to promote consistency. PROSPERO REGISTRATION NUMBER CRD42018090597.
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Affiliation(s)
- Zhe Li
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
| | - Emily Dawson
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
| | - Jessica Moodie
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
| | - Janet Martin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
| | - Rodrigo Bagur
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Davy Cheng
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
- Department of Medicine, Division of Critical Care Medicine, London Health Sciences Centre, London, Ontario, Canada
| | - Bob Kiaii
- Department of Surgery, Division of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada
| | - Adam Hashi
- Faculty of Sciences, Western University, London, Ontario, Canada
| | - Ran Bi
- Schulich Interfaculty Program in Public Health, Western University, London, Ontario, Canada
| | - Michelle Yeschin
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Ava John-Baptiste
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- Department of Anesthesia & Perioperative Medicine, Western University, London, Ontario, Canada
- Centre for Medical Evidence, Decision Integrity & Clinical Impact (MEDICI), Western University, London, Ontario, Canada
- Schulich Interfaculty Program in Public Health, Western University, London, Ontario, Canada
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Margarit JA, Pajares MA, García-Camacho C, Castaño-Ruiz M, Gómez M, García-Suárez J, Soto-Viudez MJ, López-Menéndez J, Martín-Gutiérrez E, Blanco-Morillo J, Mateo E, Hernández-Acuña C, Vives M, Llorens R, Fernández-Cruz J, Acosta J, Pradas-Irún C, García M, Aguilar-Blanco EM, Castaño B, López S, Bel A, Gabaldón T, Fernández-López AR, Gutiérrez-Carretero E, López-Forte C, Moreno J, Galán J, Osseyran F, Bustamante-Munguira J, Veiras S, Vicente R. Vía clínica de recuperación intensificada en cirugía cardiaca. Documento de consenso de la Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), la Sociedad Española de Cirugía Cardiovascular y Endovascular (SECCE) y la Asociación Española de Perfusionistas (AEP). CIRUGIA CARDIOVASCULAR 2021. [DOI: 10.1016/j.circv.2020.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Zhang XM, Jiao J, Xie XH, Wu XJ. The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis. J Am Med Dir Assoc 2021; 22:527-534. [PMID: 33549566 DOI: 10.1016/j.jamda.2021.01.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of our meta-analysis was to update evidence for the association between frailty and delirium in different types of hospitalized patients, given the large volume of new studies with inconsistent results. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS In this updated meta-analysis, we searched 3 databases (Embase, PubMed, and the Cochrane Library) for observational studies, exploring the association between frailty and delirium from database inception to September 21, 2020, among hospitalized patients. Relevant data were extracted from the studies that were included. A random effects model was conducted to synthesize and pool the effect size of frailty on delirium due to different frailty score instruments, different countries, and various delirium assessments that were used. The participants enrolled in this meta-analysis were hospitalized patients. MEASURES Delirium risk due to frailty. RESULTS A total of 30 independent studies from 9 countries, consisting of 217,623 patients, was identified, and the prevalence of frailty ranged from 16.20% to 78.00%. Frail patients exhibited an increased risk for delirium compared to those without frailty [odds ratio (OR) 2.96, 95% confidence interval (CI) 2.36-3.71]. In addition, different types of hospitalized patients had various OR values, which were 2.43 for selective surgical patients (95% CI 1.88-3.14), 3.61 for medical patients (95% CI 3.61-7.89), 3.76 for urgent surgical patients (95% CI 2.88-4.92), and 6.66 for emergency or critical illness patients (95% CI 1.41-31.47). Subgroup analysis based on the frailty score instrument showed the association still existed when using the Clinical Frailty Scale (OR 4.07, 95% CI 2.71-6.11), FRAIL Scale (OR 2.83, 95% CI 1.56-5.13), Frailty Index (OR 6.15, 95% CI 3.75-10.07), frailty phenotype (OR 2.30, 95%CI 1.35-5.66), or Erasmus Frailty Score (OR 2.79, 95% CI 1.63-4.77). However, an association between frailty and delirium was not observed when the Edmonton Frail Scale was used (OR 1.45, 95% CI 0.91-2.30). CONCLUSIONS AND IMPLICATIONS A 2.96-fold incremental risk of delirium in frail patients underscores the need for early screening of frailty and comprehensive delirium prevention. Appropriate interventions by clinicians should be performed to manage delirium, potentially reducing adverse clinical outcomes for hospitalized patients.
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Affiliation(s)
- Xiao-Ming Zhang
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Jing Jiao
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Xiao-Hua Xie
- Shenzhen Second People's Hospital, Shenzhen, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China.
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Mart MF, Williams Roberson S, Salas B, Pandharipande PP, Ely EW. Prevention and Management of Delirium in the Intensive Care Unit. Semin Respir Crit Care Med 2021; 42:112-126. [PMID: 32746469 PMCID: PMC7855536 DOI: 10.1055/s-0040-1710572] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.
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Affiliation(s)
- Matthew F. Mart
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
| | - Shawniqua Williams Roberson
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Bioengineering, Vanderbilt University, Nashville, Tennessee
| | - Barbara Salas
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Pratik P. Pandharipande
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Division of Critical Care Medicine, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - E. Wesley Ely
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, Tennessee
- Vanderbilt Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
- VA Tennessee Valley Healthcare System Geriatric Research Education and Clinical Center (GRECC), Nashville, Tennessee
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Modified Frailty Index Independently Predicts Postoperative Delirium and Delayed Neurocognitive Recovery After Elective Total Joint Arthroplasty. J Arthroplasty 2021; 36:449-453. [PMID: 32863073 DOI: 10.1016/j.arth.2020.07.074] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/02/2020] [Accepted: 07/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) and delayed neurocognitive recovery are 2 common subtypes of postoperative neurocognitive disorders that occur after total joint arthroplasty (TJA), associated with inferior surgical outcomes. The modified frailty index (mFI) reflects the status of physiologic decline and predicts adverse outcomes in various surgical patient cohorts. This study aims at examining the discriminatory value of the mFI to predict POD and delayed neurocognitive recovery after TJA. METHODS The study includes 383 participants admitted for primary elective TJA under general anesthesia combined with inhalation agents over the period from January 2018 to December 2019. POD and delayed neurocognitive recovery, based on the criteria provided by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (2013), were assessed for each enrolled patient. A multivariate logistic regression analysis was performed to screen potential risk factors for POD and delayed neurocognitive recovery. RESULTS The total incidence of POD and the delayed neurocognitive recovery of this cohort were 17.2% (66/383) and 24.8% (95/383), respectively. Our data from the multivariate logistic regression analysis indicated that a higher age (≥72 years) and a higher mFI level (≥0.18) were 2 independent risk factors for both POD and delayed neurocognitive recovery in elderly subjects after TJA. CONCLUSION The mFI may be a promising predictor for both POD and delayed neurocognitive recovery in elderly subjects following TJA. Preoperative mFI evaluation can be used for risk stratification and offers significant potential in clinical application.
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Wilson JE, Mart MF, Cunningham C, Shehabi Y, Girard TD, MacLullich AMJ, Slooter AJC, Ely EW. Delirium. Nat Rev Dis Primers 2020; 6:90. [PMID: 33184265 PMCID: PMC9012267 DOI: 10.1038/s41572-020-00223-4] [Citation(s) in RCA: 404] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/29/2020] [Indexed: 02/06/2023]
Abstract
Delirium, a syndrome characterized by an acute change in attention, awareness and cognition, is caused by a medical condition that cannot be better explained by a pre-existing neurocognitive disorder. Multiple predisposing factors (for example, pre-existing cognitive impairment) and precipitating factors (for example, urinary tract infection) for delirium have been described, with most patients having both types. Because multiple factors are implicated in the aetiology of delirium, there are likely several neurobiological processes that contribute to delirium pathogenesis, including neuroinflammation, brain vascular dysfunction, altered brain metabolism, neurotransmitter imbalance and impaired neuronal network connectivity. The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) is the most commonly used diagnostic system upon which a reference standard diagnosis is made, although many other delirium screening tools have been developed given the impracticality of using the DSM-5 in many settings. Pharmacological treatments for delirium (such as antipsychotic drugs) are not effective, reflecting substantial gaps in our understanding of its pathophysiology. Currently, the best management strategies are multidomain interventions that focus on treating precipitating conditions, medication review, managing distress, mitigating complications and maintaining engagement to environmental issues. The effective implementation of delirium detection, treatment and prevention strategies remains a major challenge for health-care organizations globally.
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Affiliation(s)
- Jo Ellen Wilson
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA.
- Department of Psychiatry and Behavioral Sciences, Division of General Psychiatry, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Matthew F Mart
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Colm Cunningham
- School of Biochemistry & Immunology, Trinity Biomedical Sciences Institute & Trinity College Institute of Neuroscience, Trinity College Dublin, Dublin, Republic of Ireland
| | - Yahya Shehabi
- Monash Health School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Prince of Wales Clinical School of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Timothy D Girard
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Geriatric Medicine, Usher Institute, University of Edinburgh, Edinburgh, Scotland, UK
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - E Wesley Ely
- Center for Critical Illness, Brain Dysfunction, and Survivorship (CIBS), Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Medicine, Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN, USA
- Veteran's Affairs TN Valley, Geriatrics Research, Education and Clinical Center (GRECC), Nashville, TN, USA
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Sillner AY, McConeghy RO, Madrigal C, Culley DJ, Arora RC, Rudolph JL. The Association of a Frailty Index and Incident Delirium in Older Hospitalized Patients: An Observational Cohort Study. Clin Interv Aging 2020; 15:2053-2061. [PMID: 33173286 PMCID: PMC7646464 DOI: 10.2147/cia.s249284] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/12/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction/Background Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty. Purpose The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium. Methods A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder. Main Outcomes and Measures Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview. Results A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25–0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p=0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p=0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium. Conclusion This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.
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Affiliation(s)
- Andrea Yevchak Sillner
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Nursing, The Pennsylvania State University, University Park, PA, USA
| | - Robert Owens McConeghy
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Caroline Madrigal
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rakesh C Arora
- Max Rady College of Medicine, Department of Surgery, University of Manitoba, Manitoba, ON, Canada.,Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, ON, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Warren Alpert Medical School and School of Public Health, Brown University, Providence, RI, USA
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Tasbihgou SR, Dijkstra S, Atmosoerodjo SD, Tigchelaar I, Huet R, Mariani MA, Absalom AR. A prospective pilot study assessing levels of preoperative physical activity and postoperative neurocognitive disorder among patients undergoing elective coronary artery bypass graft surgery. PLoS One 2020; 15:e0240128. [PMID: 33048965 PMCID: PMC7553306 DOI: 10.1371/journal.pone.0240128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/20/2020] [Indexed: 11/17/2022] Open
Abstract
Physical inactivity and a sedentary lifestyle are associated with a chronic low-level inflammatory state which has been implicated in the pathogenesis of cardiovascular disease. There is growing interest in exercise programs as part of surgical ‘prehabilitation’. We therefore studied preoperative physical activity levels of patients undergoing elective Coronary Artery Bypass Graft (CABG) surgery, and performed an exploratory analysis of the influence of physical activity on postoperative outcome. The Short Questionnaire to Assess Health (SQUASH) was used to assess physical activity among 100 patients, of mean (SD) age 65.4 (7.6) years. Additionally, handgrip strength was measured, and the get-up-and-go test was conducted. Anxiety, depression, and quality of life were assessed, and a computerised cognitive test battery was used to assess cognitive performance preoperatively, and three months after surgery. Preoperatively, 76% of patients met the recommended national guidelines for physical activity. The incidence of pre-existing medical conditions, and other pre-operative patient features were similar in active and inactive patients. Preoperative physical activity was significantly inversely related to the logistic EuroSCORE. The level of physical activity was also significantly inversely related with preoperative C-reactive protein (CRP) and peak postoperative CRP, but physical activity did not appear to be associated with any adverse postoperative outcomes or extended length of hospital stay. The incidence of postoperative neurocognitive disorder (PNCD) at 3 months postoperatively was 26%. Cognitive performance was not related with physical activity levels. In summary, this was the first study to assess activity levels of cardiac surgical patients with the SQUASH questionnaire. The majority of patients were physically active. Although physical activity was associated with lower levels of inflammation in this pilot study, it was not associated with an improved clinical or cognitive postoperative outcome.
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Affiliation(s)
- Setayesh R Tasbihgou
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sandra Dijkstra
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sawal D Atmosoerodjo
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Iris Tigchelaar
- Laboratory for Experimental Ophthalmology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Rolf Huet
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Anthony R Absalom
- Department of Anesthesiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
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Franzotti SADS, Sloboda DA, Silva JR, Souza EAS, Reboreda JZ, Ferretti-Rebustini REDL, Nogueira LDS. Performance of Severity Indices to Estimate Postoperative Complications of Myocardial Revascularization. Arq Bras Cardiol 2020; 115:452-459. [PMID: 33027367 PMCID: PMC9363080 DOI: 10.36660/abc.20190120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 09/10/2019] [Indexed: 01/15/2023] Open
Abstract
Fundamento Os pacientes em pós-operatório (PO) de cirurgia de revascularização miocárdica (CRM) internados em unidade de terapia intensiva (UTI) apresentam risco de complicações que aumentam o tempo de permanência e a morbimortalidade. Portanto, é fundamental o reconhecimento precoce desses riscos para otimizar estratégias de prevenção e desfecho clínico satisfatório. Objetivo Analisar o desempenho de índices de gravidade na predição de complicações em pacientes no PO de CRM durante a permanência na UTI. Métodos Estudo transversal, com análise retrospectiva de prontuários eletrônicos de pacientes com idade ≥ 18 anos submetidos à CRM isolada e admitidos na UTI de um hospital cardiológico, em São Paulo, Brasil. As áreas sob as curvas receiver operating characteristic (AUC) com intervalo de confiança de 95% foram analisadas para verificar a acurácia dos índices European System for Cardiac Operative Risk Evaluation (EuroScore), Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II) e Sequential Organ Failure Assessment (SOFA) na predição de complicações. Resultados A casuística foi composta por 366 pacientes (64,58±9,42 anos; 75,96% sexo masculino). As complicações identificadas foram respiratórias (24,32%), cardiológicas (19,95%), neurológicas (10,38%), hematológicas (10,38%), infecciosas (6,56%) e renais (3,55%). O APACHE II apresentou satisfatório desempenho para a predição de complicações neurológicas (AUC 0,72) e renais (AUC 0,78). Conclusão O APACHE II se destacou na previsão das complicações neurológicas e renais. Nenhum dos índices teve bom desempenho na predição das outras complicações analisadas. Portanto, os índices de gravidade não devem ser utilizados indiscriminadamente com o objetivo de predizer todas as complicações frequentemente apresentadas por pacientes após CRM. (Arq Bras Cardiol. 2020; 115(3):452-459)
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Affiliation(s)
| | | | - Juliana Rosendo Silva
- Universidade de São Paulo Faculdade de Medicina Hospital das Clínicas Instituto do Coração, São Paulo, SP - Brasil
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Li HC, Wei YC, Hsu RB, Chi NH, Wang SS, Chen YS, Chen SY, Chen CCH, Inouye SK. Surviving and Thriving 1 Year After Cardiac Surgery: Frailty and Delirium Matter. Ann Thorac Surg 2020; 111:1578-1584. [PMID: 32949611 DOI: 10.1016/j.athoracsur.2020.07.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 06/23/2020] [Accepted: 07/07/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND We compared 1-year functional outcomes for 4 cardiac surgery patient groups: comparison (without preoperative frailty or postoperative delirium [POD]), frailty only (with preoperative frailty only), POD only (with POD only), and frailty-POD (combined frailty and POD). METHODS Consecutive cardiac surgery patients (n = 298) at a university hospital were assessed for preoperative frailty using Fried's phenotype, and POD was assessed daily for 10 days after surgery using the Confusion Assessment Method. Functional outcomes (Barthel Index for activities of daily living [ADL]) and all-cause mortality were evaluated 1-year after surgery. RESULTS Preoperative frailty presented in 85 of participants (28.5%) and POD in 38 (12.8%). Frail participants were at increased risk for POD (odds ratio = 4.9; P < .001). Overall, 1-year mortality was 4.0% (n = 12) and functional change was 0.4 ± 11.0 Barthel points. Controlling for age, cardiac risk, and baseline ADL, frailty-only and comparison participants had comparable 1-year functional outcomes. The POD-only group had greater mortality (adjusted hazard ratio = 23.9; P = .01), whereas the combined frailty-POD group had the greatest ADL decline (β = -23.7; P = .01) and the highest mortality (adjusted hazard ratio = 30.2; P = .006) compared with the comparison group. CONCLUSIONS Preoperative frailty alone did not negatively affect cardiac surgery patients' functional outcomes up to 1 year, but coexisting frailty and POD led to substantial loss of independence on 3 to 4 ADLs and a 30.2-fold higher likelihood of dying 1 year after surgery. Because frailty led to a 4.9-fold increase in POD risk, frailty may serve as a presurgical screen to identify patients who would likely benefit from delirium prevention and functional recovery programs to maximize 1-year postsurgical outcomes.
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Affiliation(s)
- Hsiu-Ching Li
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yu-Chung Wei
- Graduate Institute of Statistics and Information Science, National Changhua University of Education, Changhua, Taiwan
| | - Ron-Bin Hsu
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Nai-Hsin Chi
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Shoei-Shen Wang
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan; Department of Surgery, Division of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan
| | - Yih-Sharng Chen
- Division of Cardiology, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Ssu-Yuan Chen
- Division of Physical Medicine and Rehabilitation, Fu Jen Catholic University Hospital and Fu Jen Catholic University College of Medicine, New Taipei City, Taiwan
| | - Cheryl Chia-Hui Chen
- School of Nursing, National Taiwan University College of Medicine, Taipei, Taiwan; Department of Nursing, National Taiwan University Hospital, Taipei, Taiwan.
| | - Sharon K Inouye
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts; Marcus Institute for Aging Research, Hebrew Senior Life, Boston, Massachusetts
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Rao A, Shi SM, Afilalo J, Popma JJ, Khabbaz KR, Laham RJ, Guibone K, Marcantonio ER, Kim DH. Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement. Clin Interv Aging 2020; 15:1471-1479. [PMID: 32921993 PMCID: PMC7455771 DOI: 10.2147/cia.s257079] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/01/2020] [Indexed: 12/15/2022] Open
Abstract
Background Delirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction. Objective To examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level. Design Prospective cohort, 2014-2017. Setting Single academic center. Subjects A total of 187 patients undergoing SAVR (n=77) or TAVR (n=110). Methods The Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0-12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium. Results Delirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10-12 (28.2%), 7-9 (34.5%), 4-6 (37.5%) and 0-3 (44.1%) (p-for-trend=0.001). A model that included gait speed <0.46 meter/second (OR, 2.7; 95% CI, 1.2-6.4), chair stands time ≥11.2 seconds (OR, 3.5; 95% CI, 1.0-12.4), MMSE <24 points (OR, 2.9; 95% CI, 1.3-6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1-13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5-45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035). Conclusion Assessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.
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Affiliation(s)
- Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Sandra M Shi
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
| | - Jonathan Afilalo
- Division of Cardiology and Centre for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
| | - Jeffrey J Popma
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kamal R Khabbaz
- Division of Cardiac Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Roger J Laham
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kimberly Guibone
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Edward R Marcantonio
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dae Hyun Kim
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
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Itagaki A, Sakurada K, Matsuhama M, Yajima J, Yamashita T, Kohzuki M. Impact of frailty and mild cognitive impairment on delirium after cardiac surgery in older patients. J Cardiol 2020; 76:147-153. [DOI: 10.1016/j.jjcc.2020.02.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 12/06/2019] [Accepted: 02/08/2020] [Indexed: 02/03/2023]
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The Acutely Failing Heart Plus Failing Brain Equals Double Trouble: Clinical Significance of Intensive Care Unit Delirium in Patients With Heart Failure. Can J Cardiol 2020; 36:1580-1582. [PMID: 32619445 DOI: 10.1016/j.cjca.2020.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/23/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
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Otsuka R, Oyanagi K, Hokari M, Shinoda T, Harada J, Shimogai T, Takahashi Y, Kitai T, Iwata K, Tsubaki A. Preoperative physical performance-related postoperative delirium in patients after cardiovascular surgery. Arch Gerontol Geriatr 2020; 91:104172. [PMID: 32707522 DOI: 10.1016/j.archger.2020.104172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 06/15/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This investigation clarified the relationship between a short physical performance battery (SPPB) that can comprehensively and safely evaluate balance function, walking ability, lower limb muscle strength, and postoperative delirium. METHODS This was a retrospective observational study performed at Kobe City Medical Center General Hospital. Patients who underwent surgery at the Kobe City Medical Center General Hospital Cardiovascular Surgery from August 1, 2016 to July 31, 2017 were included. Preoperative physical functions were obtained. Those showing positive results using the confusion assessment method for intensive care unit (ICU) during the ICU stay were considered as the delirium group, and the postoperative and non-postoperative delirium groups were compared. A multiple logistic regression analysis was performed with the presence or absence of onset of delirium as the dependent variable and the SPPB total score and age as dependent variables. RESULTS There were 193 subjects in this study (120 males and 73 females). Sixteen patients (8.4 %) had postoperative delirium. The age in the postoperative delirium group was significantly higher than in the postoperative delirium group (77.8 (7.0) years vs. 70.0 (11.1) years). BMI and SPPB total score were significantly lower in the postoperative delirium group. From the multiple logistic regression, the SPPB total score (OR: 0.754, 95 % CI: 0.643-0.883, p < 0.001) was extracted as a factor related to postoperative delirium onset. CONCLUSION It was illuminated that in patients with cardiovascular surgery, preoperative low physical function was not affected by age and became a risk factor of postoperative delirium onset.
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Affiliation(s)
- Ryohei Otsuka
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan; Graduate School of Niigata University of Health and Welfare, 1398 Shimami-cho, Kita-ku, Niigata City, Niigata Prefecture, Japan.
| | - Keiichi Oyanagi
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Misaki Hokari
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan; Graduate School of Niigata University of Health and Welfare, 1398 Shimami-cho, Kita-ku, Niigata City, Niigata Prefecture, Japan
| | - Taku Shinoda
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Jumpei Harada
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Takayuki Shimogai
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Yusuke Takahashi
- Department of Rehabilitation, Kaetsu Hospital, 1459-1 Higashi Kanazawa, Akiha-ku, Niigata City, Niigata Prefecture, Japan
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Kentaro Iwata
- Department of Rehabilitation, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe City, Hyogo Prefecture, Japan
| | - Atsuhiro Tsubaki
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, 1398 Shimami-cho, Kita-ku, Niigata City, Niigata Prefecture, Japan
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Dubiel C, Hiebert BM, Stammers AN, Sanjanwala RM, Tangri N, Singal RK, Manji RA, Rudolph JL, Arora RC. Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery. J Thorac Cardiovasc Surg 2020; 163:725-734. [DOI: 10.1016/j.jtcvs.2020.07.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 07/02/2020] [Accepted: 07/09/2020] [Indexed: 01/07/2023]
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Hughes CG, Boncyk CS, Culley DJ, Fleisher LA, Leung JM, McDonagh DL, Gan TJ, McEvoy MD, Miller TE. American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention. Anesth Analg 2020; 130:1572-1590. [PMID: 32022748 DOI: 10.1213/ane.0000000000004641] [Citation(s) in RCA: 147] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.
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Affiliation(s)
- Christopher G Hughes
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christina S Boncyk
- From the Department of Anesthesiology, Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Deborah J Culley
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lee A Fleisher
- Department of Anesthesiology & Critical Care, Penn Center for Perioperative Outcomes Research and Transformation, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jacqueline M Leung
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - David L McDonagh
- Departments of Anesthesiology and Pain Management, Neurological Surgery, and Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tong J Gan
- Department of Anesthesiology, Stony Brook University Renaissance School of Medicine, Stony Brook, New York
| | - Matthew D McEvoy
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
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Bando K. Commentary: Appropriate frailty measures should be incorporated into the development of accurate risk calculation models for evaluation of transcatheter aortic valve replacement candidates. J Thorac Cardiovasc Surg 2020; 161:2103-2104. [PMID: 32482406 DOI: 10.1016/j.jtcvs.2020.04.107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Revised: 04/11/2020] [Accepted: 04/13/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Ko Bando
- Department of Cardiac Surgery, The Jikei University School of Medicine, Minato-ku, Tokyo, Japan.
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70
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Volume of frail patients predicts outcome in frail patients after cardiac surgery. J Thorac Cardiovasc Surg 2020; 163:151-160.e6. [DOI: 10.1016/j.jtcvs.2020.04.097] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 04/03/2020] [Accepted: 04/14/2020] [Indexed: 11/19/2022]
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Nomura Y, Nakano M, Bush B, Tian J, Yamaguchi A, Walston J, Hasan R, Zehr K, Mandal K, LaFlam A, Neufeld KJ, Kamath V, Hogue CW, Brown CH. Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change. Anesth Analg 2020; 129:507-514. [PMID: 30540612 DOI: 10.1213/ane.0000000000003967] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Frailty is a geriatric syndrome thought to identify the most vulnerable older adults, and morbidity and mortality has been reported to be higher for frail patients after cardiac surgery compared to nonfrail patients. However, the cognitive consequences of frailty after cardiac surgery have not been well described. In this study, we examined the hypothesis that baseline frailty would be associated with postoperative delirium and cognitive change at 1 and 12 months after cardiac surgery. METHODS This study was nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. Before surgery, patients were assessed with the validated "Fried" frailty scale, which evaluates 5 domains (shrinking, weakness, exhaustion, low physical activity, and slowed walking speed) and classifies patients as nonfrail, prefrail, and frail. The primary outcome was postoperative delirium during hospitalization, which was assessed using the Confusion Assessment Method, Confusion Assessment Method for the Intensive Care Unit, and validated chart review. Neuropsychological testing was a secondary outcome and was generally performed within 2 weeks of surgery and then 4-6 weeks and 1 year after surgery, and the outcome of interest was change in composite Z-score of the test battery. Associations were analyzed using logistic and linear regression models, with adjustment for variables considered a priori (age, gender, race, education, and logistic European System for Cardiac Operative Risk Evaluation). Multiple imputation was used to account for missing data at the 12-month follow-up. RESULTS Data were available from 133 patients with baseline frailty assessments. Compared to nonfrail patients (13% delirium incidence), the incidence of delirium was higher in prefrail (48% delirium incidence; risk difference, 35%; 95% CI, 10%-51%) and frail patients (48% delirium incidence; risk difference, 35%; 95% CI, 7%-53%). In both univariable and multivariable models, the odds of delirium were significantly higher for prefrail (adjusted odds ratio, 6.43; 95% CI, 1.31-31.64; P = .02) and frail patients (adjusted odds ratio, 6.31; 95% CI, 1.18-33.74; P = .03) compared to nonfrail patients. The adjusted decline in composite cognitive Z-score was greater from baseline to 1 month only in frail patients compared to nonfrail patients. By 1 year after surgery, there were no differences in the association of baseline frailty with change in cognition. CONCLUSIONS Compared to nonfrail patients, both prefrail and frail patients were at higher risk for the primary outcome of delirium after cardiac surgery. Frail patients were also at higher risk for the secondary outcome of greater decline in cognition from baseline to 1 month, but not baseline to 1 year, after surgery.
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Affiliation(s)
- Yohei Nomura
- From the Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Mitsunori Nakano
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Brian Bush
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jing Tian
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Atsushi Yamaguchi
- From the Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | | | | | - Kenton Zehr
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kaushik Mandal
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew LaFlam
- School of Medicine, Tufts University, Medford, Massachusetts
| | | | - Vidyulata Kamath
- Division of Medical Psychology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Charles W Hogue
- Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Souza Leite W, Novaes A, Bandeira M, Olympia Ribeiro E, dos Santos AM, de Moura PH, Morais CC, Rattes C, Richtrmoc MK, Souza J, Correia de Lima GH, Pinheiro Modolo NS, Gonçalves ACE, Ramirez Gonzalez CA, do Amparo Andrade M, Dornelas De Andrade A, Cunha Brandão D, Lima Campos S. Patient-ventilator asynchrony in conventional ventilation modes during short-term mechanical ventilation after cardiac surgery: randomized clinical trial. Multidiscip Respir Med 2020; 15:650. [PMID: 32373344 PMCID: PMC7196928 DOI: 10.4081/mrm.2020.650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 03/27/2020] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION AND AIM Studies regarding asynchrony in patients in the cardiac postoperative period are still only a few. The main objective of our study was to compare asynchronies incidence and its index (AI) in 3 different modes of ventilation (volume-controlled ventilation [VCV], pressure-controlled ventilation [PCV] and pressure-support ventilation [PSV]) after ICU admission for postoperative care. METHODS A prospective parallel randomised trialin the setting of a non-profitable hospital in Brazil. The participants were patients scheduled for cardiac surgery. Patients were randomly allocated to VCV or PCV modes of ventilation and later both groups were transitioned to PSV mode. RESULTS All data were recorded for 5 minutes in each of the three different phases: T1) in assisted breath, T2) initial spontaneous breath and T3) final spontaneous breath, a marking point prior to extubation. Asynchronies were detected and counted by visual inspection method by two independent investigators. Reliability, inter-rater agreement of asynchronies, asynchronies incidence, total and specific asynchrony indexes (AIt and AIspecific) and odds of AI ≥10% weighted by total asynchrony were analysed. A total of 17 patients randomly allocated to the VCV (n=9) or PCV (n=8) group completed the study. High inter-rated agreement for AIt (ICC 0.978; IC95%, 0,963-0.987) and good reliability (r=0.945; p<0.001) were found. Eighty-two % of patients presented asynchronies, although only 7% of their total breathing cycles were asynchronous. Early cycling and double triggering had the highest rates of asynchrony with no difference between groups. The highest odds of AI ≥10% were observed in VCV regardless the phase: OR 2.79 (1.36-5.73) in T1 vs T2, p=0.005; OR 2.61 (1.27-5.37) in T1 vs T3, p=0.009 and OR 4.99 (2.37-10.37) in T2 vs T3, p<0.001. CONCLUSIONS There was a high incidence of breathing asynchrony in postoperative cardiac patients, especially when initially ventilated in VCV. VCV group had a higher chance of AI ≥10% and this chance remained high in the following PSV phases.
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Affiliation(s)
- Wagner Souza Leite
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Alita Novaes
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Monique Bandeira
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | | | - Pedro Henrique de Moura
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Caio César Morais
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Catarina Rattes
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Juliana Souza
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Norma Sueli Pinheiro Modolo
- Department of Anaesthesiology, Institute of Bioscience, School of Medicine, UNESP-Universidade Estadual Paulista, Botucatu, São Paulo, Brazil
| | | | | | - Maria do Amparo Andrade
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | | | - Daniella Cunha Brandão
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
| | - Shirley Lima Campos
- Department of Physical Therapy, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
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Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day. BMC Med 2019; 17:229. [PMID: 31837711 PMCID: PMC6911703 DOI: 10.1186/s12916-019-1458-7] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 10/30/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Delirium is a common severe neuropsychiatric condition secondary to physical illness, which predominantly affects older adults in hospital. Prior to this study, the UK point prevalence of delirium was unknown. We set out to ascertain the point prevalence of delirium across UK hospitals and how this relates to adverse outcomes. METHODS We conducted a prospective observational study across 45 UK acute care hospitals. Older adults aged 65 years and older were screened and assessed for evidence of delirium on World Delirium Awareness Day (14th March 2018). We included patients admitted within the previous 48 h, excluding critical care admissions. RESULTS The point prevalence of Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) delirium diagnosis was 14.7% (222/1507). Delirium presence was associated with higher Clinical Frailty Scale (CFS): CFS 4-6 (frail) (OR 4.80, CI 2.63-8.74), 7-9 (very frail) (OR 9.33, CI 4.79-18.17), compared to 1-3 (fit). However, higher CFS was associated with reduced delirium recognition (7-9 compared to 1-3; OR 0.16, CI 0.04-0.77). In multivariable analyses, delirium was associated with increased length of stay (+ 3.45 days, CI 1.75-5.07) and increased mortality (OR 2.43, CI 1.44-4.09) at 1 month. Screening for delirium was associated with an increased chance of recognition (OR 5.47, CI 2.67-11.21). CONCLUSIONS Delirium is prevalent in older adults in UK hospitals but remains under-recognised. Frailty is strongly associated with the development of delirium, but delirium is less likely to be recognised in frail patients. The presence of delirium is associated with increased mortality and length of stay at one month. A national programme to increase screening has the potential to improve recognition.
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Habeeb-Allah A, Alshraideh JA. Delirium post-cardiac surgery: Incidence and associated factors. Nurs Crit Care 2019; 26:150-155. [PMID: 31820554 DOI: 10.1111/nicc.12492] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/18/2019] [Accepted: 11/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Post-operative delirium among cardiac surgery patients is a prevalent complication that associated with multiple negative outcomes. AIM This study aimed to assess delirium incidence, associated factors, and outcomes for adult patients who underwent elective cardiac surgery. DESIGN An exploratory prospective cohort design was used for this study. METHODS Delirium was diagnosed by the Confusion Assessment Method for the Intensive Care Unit. Incidence, preoperative, intraoperative, and post-operative variables for 245 patients during 3-month period were collected and analysed. RESULTS Delirium developed in 9% (n = 22) of the sample. Patients with delirium were significantly older (mean age = 65.7, SD = 8.1), t (243) = -3.66, P < .05); had longer surgery time (mean time = 286.3, SD = 82.2), t (243) = -2.25, P < .05); received more blood post-surgery (t (243) = -3.86, P < .05); spent more time on mechanical ventilation (t [21.6] = -2.2, P < .05); had longer critical care unit stay (t [21.7] = -4.0, P < 0.05); and had longer hospitalization than patients without delirium. CONCLUSIONS The risk factors associated with development of delirium were advanced age and increased duration of surgery. Negative outcomes associated with delirium were increased duration of mechanical ventilation, increased volume of post-operative infused colloids and blood/products, increased critical care unit stay, and increased hospitalization. A multifactorial model for delirium risk factors should be considered to detect and work on potentially preventable delirium factors. RELEVANCE TO CLINICAL PRACTICE Post-cardiac surgery delirium leads to longer mechanical ventilation time, increased ICU stay, and prolonged hospitalization. Delirium post-cardiac surgery is potentially preventable with appropriate identification of risk factors by nurses.
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Weiss HK, Stocker BW, Weingarten N, Engelhardt KE, Cook BA, Posluszny JA. Electronic Medical Record Versus Bedside Assessment: How to Evaluate Frailty in Trauma and Emergency General Surgery Patients? J Surg Res 2019; 246:464-475. [PMID: 31635837 DOI: 10.1016/j.jss.2019.09.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 07/13/2019] [Accepted: 09/13/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Screening patients for frailty is traditionally done at the bedside. However, recent electronic medical record (EMR)-based, comorbidity-focused frailty assessments have been developed. Our objective was to determine how a common bedside frailty assessment, the trauma and emergency surgery (TEGS) frailty index (FI), compares to an EMR-based frailty assessment in predicting geriatric TEGS outcomes. MATERIALS AND METHODS We retrospectively reviewed our quality improvement project database consisting of TEGS patients ≥ 65 y old. Patients were screened with the TEGS FI, a 15-question bedside assessment, including comorbidities, physical activity, emotional health, and nutrition. Six of 15 items were retrievable from the enterprise data warehouse (EDW), storing all EMR data from Northwestern Memorial Hospital, and use to calculate the EDW frailty score. Patient characteristics and outcomes were compared between different groups. RESULTS Two hundred thirty-six geriatric TEGS patients were included, of which 75 (31.8%) were TEGS FI frail and 60 (25.4%) were EDW frail. TEGS FI frail patients had increased length of stay (LOS), loss of independence (LOI), and complications compared to TEGS FI nonfrail patients. EDW frail patients had higher LOS and complications than EDW nonfrail patients but similar LOI. TEGS FI and EDW frail patients had similar outcomes except TEGS FI-only patients more often have LOI. CONCLUSIONS Bedside frailty assessments and EMR-based assessments are both effective in identifying geriatric TEGS patients at risk for increased LOS and complications. However, bedside frailty screening was better at identifying patients who have LOI and may be a more appropriate choice when screening for frailty.
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Affiliation(s)
- Hannah K Weiss
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Benjamin W Stocker
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Noah Weingarten
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Brittany A Cook
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Joseph A Posluszny
- Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Reichart D, Rosato S, Nammas W, Onorati F, Dalén M, Castro L, Gherli R, Gatti G, Franzese I, Faggian G, De Feo M, Khodabandeh S, Santarpino G, Rubino AS, Maselli D, Nardella S, Salsano A, Nicolini F, Zanobini M, Saccocci M, Bounader K, Kinnunen EM, Tauriainen T, Airaksinen J, Seccareccia F, Mariscalco G, Ruggieri VG, Perrotti A, Biancari F. Clinical frailty scale and outcome after coronary artery bypass grafting. Eur J Cardiothorac Surg 2019; 54:1102-1109. [PMID: 29897529 DOI: 10.1093/ejcts/ezy222] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/09/2018] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES The aim of this study was to assess the impact of frailty on the outcome after coronary artery bypass grafting (CABG) and whether it may improve the predictive ability of European System for Cardiac Operative Risk Evaluation (EuroSCORE II). METHODS The Clinical Frailty Scale (CFS) was assessed preoperatively in patients undergoing isolated CABG from the multicentre E-CABG registry, and patients were stratified into 3 classes: scores 1-2, scores 3-4 and scores 5-7. RESULTS Of the 6156 patients enrolled, 39.2% had CFS scores 1-2, 57.6% scores 3-4, and 3.2% scores 5-7. Logistic regression adjusted for multiple covariates showed that the CFS was an independent predictor of hospital/30-day mortality [CFS scores 3-4, odds ratio (OR) 3.95, 95% confidence interval (CI) 2.19-7.14; CFS scores 5-7, OR 5.90, 95% CI 2.67-13.05] and resulted in an Integrated Improvement Index of 1.3 (P < 0.001) and a Net Reclassification Index of 55.6 (P < 0.001) for prediction of hospital/30-day mortality. Adding the CFS classes to EuroSCORE II resulted in an Integrated Improvement Index of 0.9 (P < 0.001) and Net Reclassification Index of 59.6 (P < 0.001) for prediction of hospital/30-day mortality with a significantly larger area under the receiver operating characteristics curve (0.809 vs 0.781, P = 0.028). The CFS was an independent predictor of mid-term mortality [CFS scores 3-4, hazard ratio (HR) 2.05, 95% CI 1.43-2.85; CFS scores 5-7, HR 3.05, 95% CI 1.83-5.06]. CONCLUSIONS The CFS predicted early- and mid-term mortality in patients undergoing isolated CABG. Further studies are needed to evaluate whether frailty may improve the estimation of the operative risk of patients undergoing adult cardiac surgery. Clinicaltrials.gov number NCT02319083.
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Affiliation(s)
| | - Stefano Rosato
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Wail Nammas
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Francesco Onorati
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Magnus Dalén
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Liesa Castro
- Hamburg University Heart Center, Hamburg, Germany
| | - Riccardo Gherli
- Department of Cardiovascular Sciences, Cardiac Surgery Unit, S. Camillo-Forlanini Hospital, Rome, Italy
| | - Giuseppe Gatti
- Division of Cardiac Surgery, Ospedali Riuniti, Trieste, Italy
| | - Ilaria Franzese
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Giuseppe Faggian
- Division of Cardiovascular Surgery, Verona University Hospital, Verona, Italy
| | - Marisa De Feo
- Department of Cardiothoracic Sciences, University of Campania, Naples, Italy
| | - Sorosh Khodabandeh
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Department of Cardiac Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Santarpino
- Cardiovascular Center, Paracelsus Medical University, Nuremberg, Germany.,Città di Lecce Hospital GVM Care&Research, Lecce, Italy
| | - Antonino S Rubino
- Centro Clinico-Diagnostico "G.B. Morgagni", Centro Cuore, Pedara, Italy
| | - Daniele Maselli
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Saverio Nardella
- Department of Cardiac Surgery, St. Anna Hospital, Catanzaro, Italy
| | - Antonio Salsano
- Division of Cardiac Surgery, University of Genoa, Genoa, Italy
| | | | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Matteo Saccocci
- Department of Cardiac Surgery, Centro Cardiologico-Fondazione Monzino IRCCS, University of Milan, Milan, Italy
| | - Karl Bounader
- Division of Cardiothoracic and Vascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - Eeva-Maija Kinnunen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tuomas Tauriainen
- Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juhani Airaksinen
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Fulvia Seccareccia
- National Center of Global Health, Istituto Superiore di Sanità, Rome, Italy
| | - Giovanni Mariscalco
- Department of Cardiovascular Sciences, Clinical Sciences Wing, University of Leicester, Glenfield Hospital, Leicester, UK
| | - Vito G Ruggieri
- Division of Cardiothoracic and Vascular Surgery, Robert Debré University Hospital, Reims, France
| | - Andrea Perrotti
- Department of Thoracic and Cardiovascular Surgery, University Hospital Jean Minjoz, Besançon, France
| | - Fausto Biancari
- Heart Center, Turku University Hospital, University of Turku, Turku, Finland.,Department of Surgery, Oulu University Hospital and University of Oulu, Oulu, Finland.,Department of Surgery, University of Turku, Turku, Finland
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Yuguchi S, Saitoh M, Oura K, Tahara M, Kamisaka K, Kawamura T, Kato M, Morisawa T, Takahashi T. Impact of preoperative frailty on regaining walking ability in patients after cardiac surgery: Multicenter cohort study in Japan. Arch Gerontol Geriatr 2019; 83:204-210. [DOI: 10.1016/j.archger.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 04/05/2019] [Accepted: 04/06/2019] [Indexed: 10/27/2022]
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Rengel KF, Pandharipande PP, Hughes CG. Special Considerations for the Aging Brain and Perioperative Neurocognitive Dysfunction. Anesthesiol Clin 2019; 37:521-536. [PMID: 31337482 DOI: 10.1016/j.anclin.2019.04.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Postoperative delirium and postoperative cognitive dysfunction (POCD) occur commonly in older adults after surgery and are frequently underrecognized. Delirium has been associated with worse outcomes, and both delirium and cognitive dysfunction increase the risk of long-term cognitive decline. Although the pathophysiology of delirium and POCD have not been clearly defined, risk factors for both include increasing age, lower levels of education, and baseline cognitive impairment. In addition, developing delirium increases the risk of POCD. This article examines interventions that may reduce the risk of developing delirium and POCD and improve long-term recovery and outcomes in the vulnerable older population.
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Affiliation(s)
- Kimberly F Rengel
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA.
| | - Pratik P Pandharipande
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
| | - Christopher G Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine, Vanderbilt University School of Medicine, 1211 21st Avenue South, 422 MAB, Nashville, TN 37212, USA
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79
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Cha S, Brown CH. Treating delirium in the intensive care unit: No easy answers. J Thorac Cardiovasc Surg 2019; 159:1895-1898. [PMID: 31303322 DOI: 10.1016/j.jtcvs.2019.02.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 02/21/2019] [Accepted: 02/21/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Stephanie Cha
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
| | - Charles H Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
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Yau DKW, Wong MKH, Wong WT, Gin T, Underwood MJ, Joynt GM, Lee A. PREhabilitation for improving QUality of recovery after ELective cardiac surgery (PREQUEL) study: protocol of a randomised controlled trial. BMJ Open 2019; 9:e027974. [PMID: 31092666 PMCID: PMC6530430 DOI: 10.1136/bmjopen-2018-027974] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 01/31/2019] [Accepted: 03/21/2019] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Frailty is a multidimensional syndrome in which multiple small physiological deficits accumulate gradually, resulting in a loss of physiological reserve and adaptability, putting a patient that is exposed to a stressor at a higher risk of adverse outcomes. Both pre-frailty and frailty are associated with poor patient outcomes and higher healthcare costs. The effect of a prehabilitation programme and standard care on the quality of recovery in pre-frail and frail patients undergoing elective cardiac surgery will be compared. METHOD AND ANALYSIS A single-centre, superiority, stratified randomised controlled trial with a blinded outcome assessment and intention-to-treat analysis. Pre-frail and frail patients awaiting elective coronary artery bypass graft, with or without valvular repair/replacement, will be recruited. 164 participants will be randomly assigned to either prehabilitation (intervention) or standard care (no intervention) groups. The prehabilitation group will attend two sessions/week of structured exercise (aerobic and resistance) training, supervised by a physiotherapist, for 6-10 weeks before surgery with early health promotion advice in addition to standard care. The standard care group will receive the usual routine care (no prehabilitation). Frailty will be assessed at baseline, hospital admission and at 1 and 3 months after surgery. The primary outcomes will be participants' perceived quality of recovery (15-item Quality of Recovery questionnaire) after surgery (day 3), days at home within 30 days of surgery and the changes in WHO Disability Assessment Schedule 2.0 score between baseline and at 1 and 3 months after surgery. Secondary outcomes will include major adverse cardiac and cerebrovascular events, psychological distress levels, health-related quality of life and healthcare costs. ETHICS AND DISSEMINATION The Joint CUHK-NTEC Clinical Research Ethics Committee approved the study protocol (CREC Ref. No. 2017.696 T). The findings will be presented at scientific meetings, in peer-reviewed journals and to study participants. TRIAL REGISTRATION NUMBER ChiCTR1800016098; Pre-results.
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Affiliation(s)
- Derek King Wai Yau
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Man Kin Henry Wong
- Department of Anaesthesia and Intensive Care, Prince of Wales Hospital, Shatin, New Territories, Hong Kong
| | - Wai-Tat Wong
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Tony Gin
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Malcolm John Underwood
- Division of Cardiothoracic Surgery, Department of Surgery, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Gavin Mathew Joynt
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Anna Lee
- Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Choutko-Joaquim S, Tacchini-Jacquier N, Pralong D'Alessio G, Verloo H. Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department. Dement Geriatr Cogn Dis Extra 2019; 9:236-249. [PMID: 31303870 PMCID: PMC6600030 DOI: 10.1159/000499707] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/17/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium. AIM To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland. METHOD A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver. RESULTS The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference. CONCLUSION Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.
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Affiliation(s)
| | | | | | - Henk Verloo
- School of Health Sciences, University of Applied Sciences and Arts Western Switzerland, Sion, Switzerland
- Consultant of Valais Hospital, Sion, Switzerland
- Scientific collaborator of the service of Old Age psychiatry, University Hospital Lausanne, Cery, Prilly, Switzerland
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Frailty as a risk predictor in cardiac surgery: Beyond the eyeball test. J Thorac Cardiovasc Surg 2019; 157:1905-1909. [DOI: 10.1016/j.jtcvs.2018.08.054] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Revised: 08/21/2018] [Accepted: 08/26/2018] [Indexed: 01/07/2023]
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83
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Zão A, Magalhães S, Santos M. Frailty in cardiovascular disease: Screening tools. Rev Port Cardiol 2019; 38:143-158. [PMID: 30879899 DOI: 10.1016/j.repc.2018.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 11/17/2017] [Accepted: 05/19/2018] [Indexed: 10/27/2022] Open
Abstract
Cardiovascular disease (CVD) is the leading cause of death in developed countries and disproportionately affects older adults. Frailty is a complex clinical syndrome with multiple causes and contributing factors in which there is increased vulnerability when exposed to a minor stressor and increased risk for adverse outcomes, such as disability, hospitalization and mortality. Frailty is an important prognostic factor in patients with CVD, and so identifying this feature when assessing these patients may help to individually tailor cardiovascular treatment. The first step is to identify frailty. Several tools have been validated as screening methods for frailty. However, they diverge with regard to complexity, nature, feasibility and the outcome they can predict. The aim of this review is to describe the available screening tools for frailty and to examine their usefulness in patients with CVD.
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Affiliation(s)
- Ana Zão
- Serviço de Medicina Física e de Reabilitação, Centro Hospitalar do Porto, Porto, Portugal.
| | - Sandra Magalhães
- Serviço de Medicina Física e de Reabilitação, Centro Hospitalar do Porto, Porto, Portugal
| | - Mário Santos
- Serviço de Cardiologia, Centro Hospitalar do Porto, Porto, Portugal; Departamento de Fisiologia e Cirurgia Cardiotorácica, Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Huisingh-Scheetz M, Martinchek M, Becker Y, Ferguson MK, Thompson K. Translating Frailty Research Into Clinical Practice: Insights From the Successful Aging and Frailty Evaluation Clinic. J Am Med Dir Assoc 2019; 20:672-678. [PMID: 30737166 DOI: 10.1016/j.jamda.2018.12.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 01/07/2023]
Abstract
Aging researchers have been studying frailty for decades. Experts agree that frailty is a medical syndrome marked by reduced physiologic function, which increases the risk of vulnerability and short-term mortality, particularly in the face of a stressor. Frailty has been shown to predict poor outcomes including falls, disability, major morbidity following surgery, and mortality among older adults. Despite hundreds of papers identifying frailty as a useful marker of risk, its translation into clinical practice has lagged. The Successful Aging and Frailty Evaluation (SAFE) clinic was established in 2011 specifically to implement routine and structured frailty assessment and management in a variety of referred patients. Now, more than 7 years after its inception, we offer our "in the trenches" clinical perspective on logistical challenges, the clinical utility of the frailty assessment, and future frailty needs and targets to help further the frailty translation research efforts.
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Affiliation(s)
- Megan Huisingh-Scheetz
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, IL.
| | - Michelle Martinchek
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, IL
| | - Yolanda Becker
- Section of Transplant Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Mark K Ferguson
- Section of Thoracic Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL
| | - Katherine Thompson
- Section of Geriatrics and Palliative Medicine, Department of Medicine, University of Chicago Medicine, Chicago, IL
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85
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Frailty in cardiovascular disease: Screening tools. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2018.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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87
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Pre-Operative Frailty Status Is Associated with Cardiac Rehabilitation Completion: A Retrospective Cohort Study. J Clin Med 2018; 7:jcm7120560. [PMID: 30562937 PMCID: PMC6306827 DOI: 10.3390/jcm7120560] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 12/26/2022] Open
Abstract
While previous investigations have demonstrated the benefit of cardiac rehabilitation (CR) on outcomes after cardiac surgery, the association between pre-operative frailty and post-operative CR completion is unclear. The purpose of this retrospective cohort study was to determine if pre-operative frailty scores impacted CR completion post-operatively and if CR completion influenced frailty scores in 114 cardiac surgery patients. Frailty was assessed with the use of the Clinical Frailty Scale (CFS), the Modified Fried Criteria (MFC), the Short Physical Performance Battery (SPPB), and the Functional Frailty Index (FFI). A Mann-Whitney test was used to compare frailty scores between CR completers and non-completers and changes in frailty scores from baseline to 1-year post-operation. CR non-completers were more frail than CR completers at pre-operative baseline based on the CFS (p = 0.01), MFC (p < 0.001), SPPB (p = 0.007), and the FFI (p < 0.001). A change in frailty scores from baseline to 1-year post-operation was not detected in either group using any of the four frailty assessments. However, greater improvements from baseline to 1-year post-operation in two MFC domains (cognitive impairment and low physical activity) and the physical domain of the FFI were found in CR completers as compared to CR non-completers. These data suggest that pre-operative frailty assessments have the potential to identify participants who are less likely to attend and complete CR. The data also suggest that frailty assessment tools need further refinement, as physical domains of frailty function appear to be more sensitive to change following CR than other domains of frailty.
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88
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Green J, Kirby K, Hope S. Ambulance clinicians' perceptions, assessment and management of frailty: thematic analysis of focus groups. Br Paramed J 2018; 3:23-33. [PMID: 33328809 PMCID: PMC7706767 DOI: 10.29045/14784726.2018.12.3.3.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Introduction: More than half of all patients attended by the South Western Ambulance Service NHS Foundation Trust are over the age of 65. In 2017, 62% of older patients who were the subject of a frailty assessment were believed to have at least mild frailty (1/5 of all patients). Frailty is an increasingly relevant concept/diagnosis and ambulance services are well positioned to identify frailty and influence the ‘care pathways’ through which patients are directed (thereby influencing health outcomes). Throughout the South Western Ambulance Service NHS Foundation Trust, a mandatory training session regarding frailty was delivered to clinical personnel in 2017 and frailty assessment tools are available on the electronic Patient Clinical Record. Aim: To explore and gain insight into the current knowledge, practice and attitudes of ambulance clinicians regarding frailty and patients with frailty. Methods: Two focus groups of ambulance clinicians (n = 8; n = 9) recruited from across the South Western Ambulance Service NHS Foundation Trust were held in October 2017. Focus group discussions were analysed thematically. Results: Knowledge of conceptual models of frailty, appropriate assessment of patients with frailty and appropriate care pathways varied substantially among focus group participants. Completion of the ‘Rockwood’ Clinical Frailty Scale for relevant patients has become routine. However, conflicting opinions were expressed regarding the context and purpose of this. The Timed-Up-and-Go mobility assessment tool is also on the electronic Patient Clinical Record, but difficulties regarding its completion were expressed. Patient management strategies ranged from treatment options which the ambulance service can provide, to referrals to primary/community care which can support the management of patients in their homes, and options to refer patients directly to hospital units or specialists with the aim of facilitating appropriate assessment, treatment and discharge. Perceptions of limited availability and geographical variability regarding these referral pathways was a major feature of the discussions, raising questions regarding awareness, capacity, inter-professional relationships and patient choice. Conclusion: Knowledge, practice and attitudes of ambulance staff, with regard to frailty, varied widely. This reflected the emerging nature of the condition, both academically and clinically, within the ambulance profession and the wider healthcare system.
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Affiliation(s)
- Jonathan Green
- South Western Ambulance Service NHS Foundation Trust: Orcid ID: 0000-0001-5738-7515
| | - Kim Kirby
- University of the West of England; South Western Ambulance Service NHS Foundation Trust: Orcid ID: 0000-0002-8092-7978
| | - Suzy Hope
- University of Exeter Medical School: Orcid ID: 0000-0001-7343-0149
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Magill ST, Dalle Ore CL, Diaz MA, Jalili DD, Raleigh DR, Aghi MK, Theodosopoulos PV, McDermott MW. Surgical outcomes after reoperation for recurrent non-skull base meningiomas. J Neurosurg 2018; 131:1179-1187. [PMID: 30544357 DOI: 10.3171/2018.6.jns18118] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Accepted: 06/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recurrent meningiomas are primarily managed with radiation therapy or repeat resection. Surgical morbidity after reoperation for recurrent meningiomas is poorly understood. Thus, the objective of this study was to report surgical outcomes after reoperation for recurrent non-skull base meningiomas. METHODS A retrospective review of patients was performed. Inclusion criteria were patients with recurrent meningioma who had prior resection and supratentorial non-skull base location. Univariate and multivariate logistic regression and recursive partitioning analysis were used to identify risk factors for surgical complications. RESULTS The authors identified 67 patients who underwent 111 reoperations for recurrent supratentorial non-skull base meningiomas. The median age was 53 years, 49% were female, and the median follow-up was 9.8 years. The most common presenting symptoms were headache, weakness, and seizure. The WHO grade after the last reoperation was grade I in 22% of cases, grade II in 51%, and grade III in 27%. The tumor grade increased at reoperation in 22% of cases. Tumors were located on the convexity (52%), parasagittal (33%), falx (31%), and multifocal (19%) locations. Tumors involved the middle third of the sagittal plane in 52% of cases. In the 111 reoperations, 48 complications occurred in 32 patients (48%). There were 26 (54%) complications requiring surgical intervention. There was no perioperative mortality. Complications included neurological deficits (14% total, 8% permanent), wound dehiscence/infection (14%), and CSF leak/pseudomeningocele/hydrocephalus (9%). Tumors that involved the middle third of the sagittal plane (OR 6.97, 95% CI 1.5-32.0, p = 0.006) and presentation with cognitive changes (OR 20.7, 95% CI 2.3-182.7, p = 0.001) were significantly associated with complication occurrence on multivariate analysis. The median survival after the first reoperation was 11.5 years, and the 2-, 5-, and 10-year Kaplan-Meier survival rates were 91.0%, 68.8%, and 50.0%, respectively. CONCLUSIONS Reoperation for recurrent supratentorial non-skull base meningioma is associated with a high rate of complications. Patients with cognitive changes and tumors that overlap the middle third of the sagittal plane are at increased risk of complications. Nevertheless, excellent long-term survival can be achieved without perioperative mortality.
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Affiliation(s)
| | | | | | | | - David R Raleigh
- Departments of1Neurological Surgery and
- 2Radiation Oncology, University of California, San Francisco, California
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Terazawa S, Oshima H, Narita Y, Fujimoto K, Mutsuga M, Tokuda Y, Yoshizumi T, Ito H, Uchida W, Usui A. Strategy of Cardiovascular Surgery for Patients With Dementia as Evaluated by Mini-Mental State Examination. Circ J 2018; 82:2998-3004. [PMID: 30259878 DOI: 10.1253/circj.cj-18-0312] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The strategy for cardiovascular surgery in dementia patients is controversial, so we aimed to investigate whether preoperative dementia and its severity might affect the outcomes of cardiovascular surgery by evaluating with the Mini-Mental State Examination (MMSE). Methods and Results: The study group comprised 490 patients undergoing cardiovascular surgery. Their preoperative cognitive status was evaluated using the MMSE, and analysis was performed to compare the patients with MMSE score <24 (dementia group, n=51) or MMSE score 24-30 (non-dementia group, n=439). Furthermore, the effect of the severity of dementia was analyzed with a cut-off MMSE score of 19/20. Risk factors for surgical outcomes were explored using multivariate logistic regression analysis. Hospital mortality was 11.8% in the dementia group and 2.1% in the non-dementia group (P=0.002). Regarding the postoperative morbidities, the incidence of cerebrovascular disorder (P=0.001), pneumonia (P=0.039), delirium (P=0.004), and infection (P=0.006) was more frequent in dementia group. Among the patients with MMSE <20, hospital mortality was as high as 25%, and the rate of delirium was 58%. Multivariate logistic regression analysis revealed that MMSE score <24 (P=0.003), lower serum albumin (P=0.023) and aortic surgery (P=0.036) were independent risk factors for hospital death. CONCLUSIONS Preoperative dementia affects the outcomes of cardiovascular surgery with regard to hospital death and delirium. The surgical indication for patients with MMSE <20 might be difficult, but surgery with an appropriate strategy should be considered for patients with MMSE <24.
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Affiliation(s)
- Sachie Terazawa
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Hideki Oshima
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yuji Narita
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Kazuro Fujimoto
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Masato Mutsuga
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Yoshiyuki Tokuda
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Tomo Yoshizumi
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Hideki Ito
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Wataru Uchida
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
| | - Akihiko Usui
- Department of Cardiac Surgery, Nagoya University Graduate School of Medicine
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91
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Frailty indexes in perioperative and critical care: A systematic review. Arch Gerontol Geriatr 2018; 79:88-96. [DOI: 10.1016/j.archger.2018.08.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/19/2022]
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92
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Persico I, Cesari M, Morandi A, Haas J, Mazzola P, Zambon A, Annoni G, Bellelli G. Frailty and Delirium in Older Adults: A Systematic Review and Meta-Analysis of the Literature. J Am Geriatr Soc 2018; 66:2022-2030. [PMID: 30238970 DOI: 10.1111/jgs.15503] [Citation(s) in RCA: 123] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/28/2018] [Accepted: 05/31/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To evaluate the relationship between frailty and delirium. DESIGN Systematic review and meta-analysis. SETTING MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases were searched for articles on frailty and delirium published on or before October 31, 2017. PARTICIPANTS Individuals aged 65 and older. MEASUREMENTS Two authors independently reviewed all English-language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random-effects or fixed-effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I2 statistics. RESULTS We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta-analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65-2.91). There was low variability among studies in the measures of association between frailty and delirium (I2 2.24, p-value Q-statistic = .41) but high heterogeneity in the methods used to assess the two conditions. CONCLUSION This systematic review and meta-analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.
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Affiliation(s)
- Ilaria Persico
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Matteo Cesari
- Geriatric Unit, Fondazione IRCCS Ca 'Granda-Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical and Community Sciences, University of Milano, Milan, Italy
| | - Alessandro Morandi
- Department of Rehabilitation and Aged Care Unit, Ancelle della Carità Hospital, Cremona, Italy
| | - Justin Haas
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Paolo Mazzola
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy
| | - Antonella Zambon
- Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milano, Italy
| | - Giorgio Annoni
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.,Acute Geriatric Unit San Gerardo Hospital, Monza, Italy
| | - Giuseppe Bellelli
- School of Medicine and Surgery, Milano-Bicocca University, Monza, Italy.,Acute Geriatric Unit San Gerardo Hospital, Monza, Italy
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93
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Li Z, Ding X. The incremental predictive value of frailty measures in elderly patients undergoing cardiac surgery: A systematic review. Clin Cardiol 2018; 41:1103-1110. [PMID: 29974493 DOI: 10.1002/clc.23021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 06/28/2018] [Accepted: 07/03/2018] [Indexed: 12/27/2022] Open
Abstract
Emerging evidence demonstrates that frailty measures can predict adverse outcomes after cardiac procedures. Our objectives were to examine whether the inclusion of frailty measures adds incremental predictive value to existing surgical risk prediction models in patients undergoing cardiac surgery and to evaluate the reporting and methods of studies that investigated the prediction of frailty measures in cardiology. The inclusion of frailty measures adds incremental predictive value on existing perioperative risk-scoring systems. We systematically searched the EMBASE, MEDLINE, and Web of Science databases for relevant studies. Studies were included according to predefined inclusion criteria. The quality of included studies was appraised using the QUADAS-2 tool. Data were extracted and synthesized according to predefined methods. Twelve studies were included in the analysis. Included studies demonstrated the incremental predictive value of frailty measures on existing surgical risk models for mortality, but the predictive value of frailty measures alone was not consistent across literature. Few studies that investigated the predictive ability of frailty measures reported all important model performance measures. When comparing the predictive value of frailty measures with existing models, few studies reported if the frailty measurement was separately performed from the existing perioperative risk assessment. The addition of frailty measures to the existing perioperative risk models improved the prediction performance for mortality, but the incorporation of frailty assessment into perioperative risk assessment requires further evidence before making health policy recommendations.
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Affiliation(s)
- Zhe Li
- Department of Epidemiology & Biostatistics, Western University, London, Ontario
| | - Xin Ding
- Chinese Academy of Medical Sciences, Fuwai Hospital, Beijing, China
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94
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Giroux M, Sirois MJ, Boucher V, Daoust R, Gouin É, Pelletier M, Berthelot S, Voyer P, Émond M. Frailty Assessment to Help Predict Patients at Risk of Delirium When Consulting the Emergency Department. J Emerg Med 2018; 55:157-164. [DOI: 10.1016/j.jemermed.2018.02.032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 01/31/2018] [Accepted: 02/22/2018] [Indexed: 12/20/2022]
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Abstract
There is significant evidence that many older surgical patients experience at least a transient decrease in cognitive function. Although there is still equipoise regarding the degree, duration, and mechanism of cognitive dysfunction, there is a concurrent need to provide best-practice clinical evidence. The two major cognitive disorders seen after surgery are postoperative delirium and postoperative cognitive dysfunction. Delirium is a public health problem; millions of dollars are spent annually on delirium-related medical resource use and prolonged hospital stays. Postoperative cognitive dysfunction is a research construct that historically signifies decline in performance on a neuropsychiatric test or group of tests and begins days to weeks after surgery. This review focuses on the current state of information gathered by several interdisciplinary stakeholder groups. Although there is still a need for high-level evidence to guide clinical practice, there is an emerging literature that can guide practitioners.
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Affiliation(s)
- C Brown
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Sheikh Zayed Tower, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - S Deiner
- Departments of Anesthesiology .,Neurosurgery.,Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box #1010, New York, NY 10029-6574, USA
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96
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Hayashi K, Oshima H, Shimizu M, Kobayashi K, Matsui S, Nishida Y, Usui A. Preoperative 6-Minute Walk Distance Is Associated With Postoperative Cognitive Dysfunction. Ann Thorac Surg 2018; 106:505-512. [DOI: 10.1016/j.athoracsur.2018.03.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 02/18/2018] [Accepted: 03/05/2018] [Indexed: 10/16/2022]
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97
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Goins AE, Smeltz A, Ramm C, Strassle PD, Teeter EG, Vavalle JP, Kolarczyk L. General Anesthesia for Transcatheter Aortic Valve Replacement: Total Intravenous Anesthesia is Associated with Less Delirium as Compared to Volatile Agent Technique. J Cardiothorac Vasc Anesth 2018; 32:1570-1577. [DOI: 10.1053/j.jvca.2017.12.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Indexed: 12/20/2022]
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98
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Arora RC, Brown CH, Sanjanwala RM, McKelvie R. “NEW” Prehabilitation: A 3-Way Approach to Improve Postoperative Survival and Health-Related Quality of Life in Cardiac Surgery Patients. Can J Cardiol 2018; 34:839-849. [DOI: 10.1016/j.cjca.2018.03.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/16/2018] [Accepted: 03/28/2018] [Indexed: 01/03/2023] Open
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99
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De Oliveira GS. We need more studies to guide the perioperative management of high risk seniors undergoing surgery. J Clin Anesth 2018; 48:89-90. [PMID: 29800923 DOI: 10.1016/j.jclinane.2018.04.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2018] [Indexed: 01/31/2023]
Affiliation(s)
- Gildasio S De Oliveira
- Department of Anesthesiology, Rhode Island Hospital, Providence, RI, USA; Department of Surgery, Alpert School of Medicine, Brown University, Providence, RI, USA; Department of Health Services Research, School of Public Health, Providence, RI, USA.
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