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Rengel KF, Boncyk CS, DiNizo D, Hughes CG. Perioperative Neurocognitive Disorders in Adults Requiring Cardiac Surgery: Screening, Prevention, and Management. Semin Cardiothorac Vasc Anesth 2023; 27:25-41. [PMID: 36137773 DOI: 10.1177/10892532221127812] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Neurocognitive changes are the most common complication after cardiac surgery, ranging from acute postoperative delirium to prolonged postoperative neurocognitive disorder. Changes in cognition are distressing to patients and families and associated with worse outcomes overall. This review outlines definitions and diagnostic criteria, risk factors for, and mechanisms of Perioperative Neurocognitive Disorders and offers strategies for preoperative screening and perioperative prevention and management of neurocognitive complications.
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Affiliation(s)
- Kimberly F Rengel
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina S Boncyk
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniella DiNizo
- Scope Anesthesia of North Carolina, Charlotte, NC, USA.,Pulmonary and Critical Care Consultants, Carolinas Medical Center, 2351Atrium Health, Charlotte, NC, USA
| | - Christopher G Hughes
- Division of Anesthesia Critical Care Medicine, Department of Anesthesiology, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center and the Center for Health Services Research, 12328Vanderbilt University Medical Center, Nashville, TN, USA.,Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, TN, USA
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Abstract
OBJECTIVES Many studies document cognitive decline following specific types of acute illness hospitalizations (AIH) such as surgery, critical care, or those complicated by delirium. However, cognitive decline may be a complication following all types of AIH. This systematic review will summarize longitudinal observational studies documenting cognitive changes following AIH in the majority admitted population and conduct meta-analysis (MA) to assess the quantitative effect of AIH on post-hospitalization cognitive decline (PHCD). METHODS We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria were defined to identify studies of older age adults exposed to AIH with cognitive measures. 6566 titles were screened. 46 reports were reviewed qualitatively, of which seven contributed data to the MA. Risk of bias was assessed using the Newcastle-Ottawa Scale. RESULTS The qualitative review suggested increased cognitive decline following AIH, but several reports were particularly vulnerable to bias. Domain-specific outcomes following AIH included declines in memory and processing speed. Increasing age and the severity of illness were the most consistent risk factors for PHCD. PHCD was supported by MA of seven eligible studies with 41,453 participants (Cohen's d = -0.25, 95% CI [-0.02, -0.49] I2 35%). CONCLUSIONS There is preliminary evidence that AIH exposure accelerates or triggers cognitive decline in the elderly patient. PHCD reported in specific contexts could be subsets of a larger phenomenon and caused by overlapping mechanisms. Future research must clarify the trajectory, clinical significance, and etiology of PHCD: a priority in the face of an aging population with increasing rates of both cognitive impairment and hospitalization.
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Irqsusi M, Schenk Zu Schweinsberg T, Johnson FA, Dielmann K, Ramzan R, Vogt S, Mirow N, Rastan AJ. Prediction of stroke reconvalescence after coronary bypass surgery indicated by CT scan parameters. J Card Surg 2022; 37:3133-3147. [PMID: 35904236 DOI: 10.1111/jocs.16797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/22/2022] [Accepted: 06/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Stroke in the postoperative time course after heart surgery remains a serious risk. Cranial computer tomography (CCT) is the first line option to detect severe intracranial damage. However, only few data are available to predict neurological outcome. Using visual rating scales (VRSs), this study addresses reliability and effectivity to indicate neurological status and likelyhood of improvement. METHODS In a single-center retrospective evaluation, 3719 patients underwent coronary bypass surgery. Because of a delayed recovery phase and neurologic deficits after cardiac surgery 109 patients had a cranial CT scan in the early postoperative period. The incidence of clinically relevant findings within the imaging was rated by an experienced neuroradiologist using two VRS, that is, the age-related white matter changes (ARWMCs) and the Mendes-Ribeiro visual rating scale (MRVRS). Both are computer-assisted measurement schemes to detect stroke-related intracranial damage. Follow-up was investigated with regard to clinical outcome and patient-related risk profiles. RESULTS Of 109 patients with postoperative cranial CT scans due to prolonged recovery phases or proven neurological damage 44.5% had one cerebral defect in CCT imaging scans only. The others showed multiple defects. During hospital stay, 92.3% experienced neurological improvement exposing reduced ARWMC, while 7.1% had no improvement and correlating high scores. Of both scales, the ARWMC-VRS demonstrated superior accuracy and discrimination. The preoperative ejection fraction (EF), arteriosclerotic degeneration of carotid arteries, and reduced glomerular filtration rate were found to have a high correlation (r = 0.0005) with the latter group. In-hospital mortality of this cohort was 8.18%. CONCLUSION Both the ARWMC and MRVRS were found to be appropriate. They reliably discriminate the groups of stroke patients after coronary artery bypass grafting (CABG) in the analysis of CCT images. When applied at the onset of neurological symptoms both scales are able to predict neurological reconvalescence upon hospital dismission. The ARWMC scale appeared superior as it demonstrated better accuracy and discrimination. The use of both VRS in patients with suspected stroke after CABG surgery can give insightful information toward a progression of neurological dysfunction or postoperative improvement.
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Affiliation(s)
- Marc Irqsusi
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Titus Schenk Zu Schweinsberg
- Department of Diagnostic and Interventional Radiology, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Felix Allendorff Johnson
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Kai Dielmann
- Department of Anesthesiology and Intensive Care, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Rabia Ramzan
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Sebastian Vogt
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Nikolas Mirow
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
| | - Ardawan J Rastan
- Department of Cardiothoracic Surgery, University Hospital Marburg, Philipps University, Marburg, Germany
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Berger M, Browndyke JN, Cooter Wright M, Nobuhara C, Reese M, Acker L, Bullock WM, Colin BJ, Devinney MJ, Moretti EW, Moul JW, Ohlendorf B, Laskowitz DT, Waligorska T, Shaw LM, Whitson HE, Cohen HJ, Mathew JP. Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers. Ann Clin Transl Neurol 2022; 9:155-170. [PMID: 35104057 PMCID: PMC8862419 DOI: 10.1002/acn3.51499] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 12/21/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Numerous investigators have theorized that postoperative changes in Alzheimer's disease neuropathology may underlie postoperative neurocognitive disorders. Thus, we determined the relationship between postoperative changes in cognition and cerebrospinal (CSF) tau, p-tau-181p, or Aβ levels after non-cardiac, non-neurologic surgery in older adults. METHODS Participants underwent cognitive testing before and 6 weeks after surgery, and lumbar punctures before, 24 h after, and 6 weeks after surgery. Cognitive scores were combined via factor analysis into an overall cognitive index. In total, 110 patients returned for 6-week postoperative testing and were included in the analysis. RESULTS There was no significant change from before to 24 h or 6 weeks following surgery in CSF tau (median [median absolute deviation] change before to 24 h: 0.00 [4.36] pg/mL, p = 0.853; change before to 6 weeks: -1.21 [3.98] pg/mL, p = 0.827). There were also no significant changes in CSF p-tau-181p or Aβ over this period. There was no change in cognitive index (mean [95% CI] 0.040 [-0.018, 0.098], p = 0.175) from before to 6 weeks after surgery, although there were postoperative declines in verbal memory (-0.346 [-0.523, -0.170], p = 0.003) and improvements in executive function (0.394, [0.310, 0.479], p < 0.001). There were no significant correlations between preoperative to 6-week postoperative changes in cognition and CSF tau, p-tau-181p, or Aβ42 changes over this interval (p > 0.05 for each). INTERPRETATION Neurocognitive changes after non-cardiac, non-neurologic surgery in the majority of cognitively healthy, community-dwelling older adults are unlikely to be related to postoperative changes in AD neuropathology (as assessed by CSF Aβ, tau or p-tau-181p levels or the p-tau-181p/Aβ or tau/Aβ ratios). TRIAL REGISTRATION clinicaltrials.gov (NCT01993836).
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Affiliation(s)
- Miles Berger
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
| | - Jeffrey N. Browndyke
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Center for Cognitive NeuroscienceDuke UniversityDurhamNorth CarolinaUSA
- Division of Geriatric Behavioral Health, Department of Psychiatry and Behavioral MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Duke Brain Imaging and Analysis CenterDurhamNorth CarolinaUSA
| | - Mary Cooter Wright
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Chloe Nobuhara
- Duke University School of MedicineDurhamNorth CarolinaUSA
| | - Melody Reese
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Leah Acker
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - W. Michael Bullock
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian J. Colin
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Michael J. Devinney
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Eugene W. Moretti
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Judd W. Moul
- Urology Division, Department of SurgeryDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Brian Ohlendorf
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Daniel T. Laskowitz
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of NeurologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Teresa Waligorska
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Leslie M. Shaw
- Department of Pathology and Lab Medicine, Perelman School of MedicineUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Heather E. Whitson
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
- Geriatrics Research Education and Clinical Center (GRECC)Durham VA Medical CenterDurhamNCUSA
| | - Harvey J. Cohen
- Center for the Study of Aging and Human DevelopmentDuke University Medical CenterDurhamNorth CarolinaUSA
- Department of MedicineDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Joseph P. Mathew
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
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Seshadri S, Caunca MR, Rundek T. Vascular Dementia and Cognitive Impairment. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00018-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ryan CT, Rosengart TK. Commentary: Measure Twice, Cut Once. Semin Thorac Cardiovasc Surg 2020; 33:82-83. [PMID: 32615308 DOI: 10.1053/j.semtcvs.2020.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/13/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Christopher T Ryan
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Todd K Rosengart
- Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.
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Walker KA, Gottesman RF, Coresh J, Sharrett AR, Knopman DS, Mosley TH, Alonso A, Zhou Y, Wong DF, Brown CH. Association of Surgical Hospitalization with Brain Amyloid Deposition: The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) Study. Anesthesiology 2020; 132:1407-1418. [PMID: 32412719 PMCID: PMC7540736 DOI: 10.1097/aln.0000000000003255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND As more older adults undergo surgery, it is critical to understand the long-term effects of surgery on brain health, particularly in relation to the development of Alzheimer's disease. This study examined the association of surgical hospitalization with subsequent brain β-amyloid deposition in nondemented older adults. METHODS The Atherosclerosis Risk in Communities-Positron Emission Tomography (ARIC-PET) study is a prospective cohort study of 346 participants without dementia who underwent florbetapir PET imaging. Active surveillance of local hospitals and annual participant contact were used to gather hospitalization and surgical information (International Classification of Disease, Ninth Revision, Clinical Modification codes) over the preceding 24-yr period. Brain amyloid measured using florbetapir PET imaging was the primary outcome. Elevated amyloid was defined as a standardized uptake value ratio of more than 1.2. RESULTS Of the 313 participants included in this analysis (age at PET: 76.0 [SD 5.4]; 56% female), 72% had a prior hospitalization, and 50% had a prior surgical hospitalization. Elevated amyloid occurred in 87 of 156 (56%) participants with previous surgical hospitalization, compared with 45 of 87 (52%) participants who had no previous hospitalization. Participants with previous surgical hospitalizations did not show an increased odds of elevated brain amyloid (odds ratio, 1.32; 95% CI, 0.72 to 2.40; P = 0.370) after adjusting for confounders (primary analysis). Results were similar using the reference group of all participants without previous surgery (hospitalized and nonhospitalized; odds ratio, 1.58; 95% CI, 0.96 to 2.58; P = 0.070). In a prespecified secondary analysis, participants with previous surgical hospitalization did demonstrate increased odds of elevated amyloid when compared with participants hospitalized without surgery (odds ratio, 2.10; 95% CI, 1.09 to 4.05; P = 0.026). However, these results were attenuated and nonsignificant when alternative thresholds for amyloid-positive status were used. CONCLUSIONS The results do not support an association between surgical hospitalization and elevated brain amyloid.
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Affiliation(s)
- Keenan A Walker
- From the Departments of Neurology (K.A.W., R.F.G.) Radiology (D.F.W.) Anesthesiology (C.H.B.), Johns Hopkins School of Medicine, Baltimore, Maryland the Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland (R.F.G., J.C., A.R.S.) the Department of Neurology, Mayo Clinic, Rochester, Minnesota (D.S.K.) Department of Medicine, Division of Geriatrics, University of Mississippi Medical Center, Jackson, Mississippi (T.H.M.) the Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (A.A.) the Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri (Y.Z.)
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Tong C, Huang C, Wu J, Xu M, Cao H. The Prevalence and Impact of Undiagnosed Mild Cognitive Impairment in Elderly Patients Undergoing Thoracic Surgery: A Prospective Cohort Study. J Cardiothorac Vasc Anesth 2020; 34:2413-2418. [PMID: 32381306 DOI: 10.1053/j.jvca.2020.03.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 03/06/2020] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to explore the prevalence of undiagnosed mild cognitive impairment (MCI) and its association with adverse outcomes in elderly patients undergoing thoracic surgery. DESIGN A prospective cohort study. SETTING Large tertiary medical center. PARTICIPANTS The authors enrolled 170 patients aged 65 years or older who were scheduled for thoracic surgery between November 7, 2018, and April 1, 2019, at the Shanghai Chest Hospital. Patients with a history of schizophrenia or dementia disease, uncorrected vision or hearing impairment, and refusal to participate were excluded. INTERVENTIONS A total of 154 elderly patients completed the Chinese version of the Montreal Cognitive Assessment (MoCA) test preoperatively and were included in the final analysis. They were categorized into a normal group (MoCA ≥ 26 scores, group N) and an abnormal group (MoCA < 26 scores, group AN) based on test results. Delirium was assessed with the Confusion Assessment Method twice daily during the first 3 postoperative days. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of postoperative delirium (POD). Secondary outcomes included the incidence of postoperative pulmonary complications (PPCs), cardiovascular complications, other complications, intensive care unit (ICU) stay, and the hospital length of stay (LOS). The incidence of MCI before thoracic surgery in elderly patients was 49.4% (76 of 154). Compared with group N, MCI could increase the incidence of POD (14.1% v 30.3%, p = 0.016) and median LOS (4 d v 5 d, p = 0.016). However, the differences in pulmonary complications, cardiovascular and other complications, and ICU stay were not significant. Multivariable logistic regression analysis showed preoperative MCI (OR = 2.573, 95% CI =1.092 to 6.060, p = 0.031) as an independent risk factor of POD. Compared with the elderly patients without POD, POD could increase the risk of PPCs (17.5% v 35.3%, p = 0.026) and median LOS (4 d v 5 d, p < 0.001). CONCLUSIONS The incidence of MCI before thoracic surgery in elderly patients was higher and associated with a higher rate of adverse postoperative outcomes. The findings may be important for preoperative patient counseling, operative planning, and eventually reducing potential risk exposure and related outcomes.
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Affiliation(s)
- Chaoyang Tong
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Chengya Huang
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jingxiang Wu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Meiying Xu
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Cao
- Department of Anesthesiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China.
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Correa-Rodríguez M, Abu Ejheisheh M, Suleiman-Martos N, Membrive-Jiménez MJ, Velando-Soriano A, Schmidt-RioValle J, Gómez-Urquiza JL. Prevalence of Depression in Coronary Artery Bypass Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:E909. [PMID: 32225052 PMCID: PMC7230184 DOI: 10.3390/jcm9040909] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 03/20/2020] [Accepted: 03/25/2020] [Indexed: 02/07/2023] Open
Abstract
Coronary artery bypass graft surgery (CABG) might adversely affect the health status of the patients, producing cognitive deterioration, with depression being the most common symptom. The aim of this study is to analyse the prevalence of depression in patients before and after coronary artery bypass surgery. A systematic review and meta-analysis was carried out, involving a study of the past 10 years of the following databases: CINAHL, LILACS, MEDLINE, PsycINFO, SciELO, Scopus, and Web of Science. The total sample comprised n = 16,501 patients. The total number of items was n = 65, with n = 29 included in the meta-analysis. Based on the different measurement tools used, the prevalence of depression pre-CABG ranges from 19-37%, and post-CABG from 15-33%. There is a considerable presence of depression in this type of patient, but this varies according to the measurement tool used and the quality of the study. Systematically detecting depression prior to cardiac surgery could identify patients at potential risk.
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Affiliation(s)
- María Correa-Rodríguez
- Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
- Instituto de Investigación Biosanitaria, IBS, 18012 Granada, Spain
| | - Moath Abu Ejheisheh
- Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
| | - Nora Suleiman-Martos
- Faculty of Health Sciences, University of Granada, Campus Universitario de Ceuta, C/Cortadura del Valle s/n, 51001 Ceuta, Spain
| | | | - Almudena Velando-Soriano
- University Hospital Virgen de las Nieves. Andalusian Health Service. Av. de las Fuerzas Armadas 2, 18014 Granada, Spain
| | | | - José Luis Gómez-Urquiza
- Faculty of Health Sciences, University of Granada, Avenida de la Ilustración N. 60, 18016 Granada, Spain
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Tamargo CL, Botros M, Saveanu RV. The relationship between neurocognitive decline and the heart-lung machine. J Card Surg 2020; 35:1057-1061. [PMID: 32176380 DOI: 10.1111/jocs.14505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Surgery involving the use of cardiopulmonary bypass (CPB) has long been associated with cerebral changes and may also contribute to adverse neurocognitive outcomes. However, there is a debate as to whether bypass itself is responsible for these changes. We conducted a systematic literature review on PubMed, supplementing our work with recent articles from other sources to examine the current evidence on neurocognitive decline associated with CPB. While surgeries involving CPB appear to be associated with cerebral changes and potentially with neurocognitive decline, it is unclear as to whether decline is related to the procedure itself. It is possible that the impacts of CPB can be more readily observed among individuals with preoperative cognitive impairment. It is thus important to screen for subtle and more apparent preoperative cognitive impairment as a risk factor for adverse outcomes. Further research, comparing on-pump and off-pump cohorts and involving intensive screening of preoperative cognitive decline, is indicated to elucidate the true neurocognitive consequences of the heart-lung machine.
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Affiliation(s)
- Christina L Tamargo
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Mousa Botros
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
| | - Radu V Saveanu
- Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, Miami, Florida
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Abstract
PURPOSE OF REVIEW Cognitive decline is frequently reported after hospitalisation in the contexts of surgery, delirium and critical care. The question not adequately addressed is whether all types of acute hospitalisations increase the risk of cognitive decline. As acute hospitalisations are common in the elderly, who are also vulnerable to cognitive decline, this possible association is of significant concern. RECENT FINDINGS This review summarises cognitive outcomes from recent observational studies investigating acute hospitalisation (emergent and elective) in older age adults. Studies were identified from searching Medline, Embase and PsycINFO databases and citations lists. The highest incidence of cognitive decline has been reported following critical care admissions and admissions complicated by delirium, although all types of acute hospitalisations are implicated. Age is the most consistent risk factor for cognitive decline. Several etiological and therapeutic aspects are being investigated, particularly the measurement of inflammatory biomarkers and treatment with anti-inflammatory medications. SUMMARY Acute hospitalisation for any reason appears to increase the risk of cognitive decline in older adults, but the cause remains elusive. Future research must clarify the nature and modifiers of posthospitalisation cognitive change, a priority in the face of an ageing population.
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Sacli H, Kara I. Are Standard Follow-Up Parameters Sufficient to Protect Neurocognitive Functions in Patients with Diabetes Mellitus who Underwent Coronary Artery Bypass Grafting? Braz J Cardiovasc Surg 2020; 35:75-81. [PMID: 32270963 PMCID: PMC7089738 DOI: 10.21470/1678-9741-2019-0160] [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] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to compare the effectiveness of cognitive function protection between the standard follow-up parameters and advanced neuromonitoring methods in diabetic patients who underwent coronary artery bypass grafting during cardiopulmonary bypass. METHODS Study design was prospective and observational. Patients were separated into two groups, treated only with standard follow-up parameters (Group 1) and followed up with the change of regional cerebral tissue oxygenation (rSO2) by near-infrared spectroscopy (Group 2). Neurocognitive functions were evaluated preoperatively and postoperatively before discharge in all patients using the Montreal Cognitive Assessment (MoCA) test. RESULTS Cognitive functions of Group 2 patients in the postoperative period were significantly higher than Group 1 patients (P=0.001). The mean postoperative MoCA score of patients was significantly lower than the mean preoperative MoCA score in Group 1 (24.8±2.2 vs. 23.6±2.6, P=0.02). However, mild cognitive dysfunction was significantly lower in Group 2, compared to Group 1 (P=0.02). CONCLUSION In patients followed up with standard parameters, a significant decrease in cognitive function was observed in the early period. However, the use of advanced neuromonitoring methods can significantly prevent this decrease in cognitive functions.
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Affiliation(s)
- Hakan Sacli
- Sakarya University Medical Faculty Department of Cardiovascular Surgery Sakarya Turkey Department of Cardiovascular Surgery, Sakarya University Medical Faculty, Sakarya, Turkey
| | - Ibrahim Kara
- Sakarya University Medical Faculty Department of Cardiovascular Surgery Sakarya Turkey Department of Cardiovascular Surgery, Sakarya University Medical Faculty, Sakarya, Turkey
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Belrose JC, Noppens RR. Anesthesiology and cognitive impairment: a narrative review of current clinical literature. BMC Anesthesiol 2019; 19:241. [PMID: 31881996 PMCID: PMC6933922 DOI: 10.1186/s12871-019-0903-7] [Citation(s) in RCA: 101] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 12/03/2019] [Indexed: 12/14/2022] Open
Abstract
Background The impact of general anesthesia on cognitive impairment is controversial and complex. A large body of evidence supports the association between exposure to surgery under general anesthesia and development of delayed neurocognitive recovery in a subset of patients. Existing literature continues to debate whether these short-term effects on cognition can be attributed to anesthetic agents themselves, or whether other variables are causative of the observed changes in cognition. Furthermore, there is conflicting data on the relationship between anesthesia exposure and the development of long-term neurocognitive disorders, or development of incident dementia in the patient population with normal preoperative cognitive function. Patients with pre-existing cognitive impairment present a unique set of anesthetic considerations, including potential medication interactions, challenges with cooperation during assessment and non-general anesthesia techniques, and the possibility that pre-existing cognitive impairment may impart a susceptibility to further cognitive dysfunction. Main body This review highlights landmark and recent studies in the field, and explores potential mechanisms involved in perioperative cognitive disorders (also known as postoperative cognitive dysfunction, POCD). Specifically, we will review clinical and preclinical evidence which implicates alterations to tau protein, inflammation, calcium dysregulation, and mitochondrial dysfunction. As our population ages and the prevalence of Alzheimer’s disease and other forms of dementia continues to increase, we require a greater understanding of potential modifiable factors that impact perioperative cognitive impairment. Conclusions Future research should aim to further characterize the associated risk factors and determine whether certain anesthetic approaches or other interventions may lower the potential risk which may be conferred by anesthesia and/or surgery in susceptible individuals.
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Affiliation(s)
- Jillian C Belrose
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada
| | - Ruediger R Noppens
- Department of Anesthesia & Perioperative Medicine, Western University, London Health Sciences Center, 339 Windermere Rd, London, ON, N6A 5A5, Canada.
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Krause BM, Sabia S, Manning HJ, Singh-Manoux A, Sanders RD. Association between major surgical admissions and the cognitive trajectory: 19 year follow-up of Whitehall II cohort study. BMJ 2019; 366:l4466. [PMID: 31391161 PMCID: PMC6683971 DOI: 10.1136/bmj.l4466] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To quantify the association between major surgery and the age related cognitive trajectory. DESIGN Prospective longitudinal cohort study. SETTING United Kingdom. PARTICIPANTS 7532 adults with as many as five cognitive assessments between 1997 and 2016 in the Whitehall II study, with linkage to hospital episode statistics. Exposures of interest included any major hospital admission, defined as requiring more than one overnight stay during follow-up. MAIN OUTCOMES MEASURES The primary outcome was the global cognitive score established from a battery of cognitive tests encompassing reasoning, memory, and phonemic and semantic fluency. Bayesian linear mixed effects models were used to calculate the change in the age related cognitive trajectory after hospital admission. The odds of substantial cognitive decline induced by surgery defined as more than 1.96 standard deviations from a predicted trajectory (based on the first three cognitive waves of data) was also calculated. RESULTS After accounting for the age related cognitive trajectory, major surgery was associated with a small additional cognitive decline, equivalent on average to less than five months of aging (95% credible interval 0.01 to 0.73 years). In comparison, admissions for medical conditions and stroke were associated with 1.4 (1.0 to 1.8) and 13 (9.6 to 16) years of aging, respectively. Substantial cognitive decline occurred in 2.5% of participants with no admissions, 5.5% of surgical admissions, and 12.7% of medical admissions. Compared with participants with no major hospital admissions, those with surgical or medical events were more likely to have substantial decline from their predicted trajectory (surgical admissions odds ratio 2.3, 95% credible interval 1.4 to 3.9; medical admissions 6.2, 3.4 to 11.0). CONCLUSIONS Major surgery is associated with a small, long term change in the average cognitive trajectory that is less profound than for major medical admissions. The odds of substantial cognitive decline after surgery was about doubled, though lower than for medical admissions. During informed consent, this information should be weighed against the potential health benefits of surgery.
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Affiliation(s)
- Bryan M Krause
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792-3272, USA
| | - Séverine Sabia
- Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, Université de Paris, France
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Helen J Manning
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, WI, USA
| | - Archana Singh-Manoux
- Inserm U1153, Epidemiology of Ageing and Neurodegenerative diseases, Université de Paris, France
- Department of Epidemiology and Public Health, University College London, London, UK
| | - Robert D Sanders
- Department of Anesthesiology, University of Wisconsin, Madison, WI 53792-3272, USA
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Greaves D, Psaltis PJ, Ross TJ, Davis D, Smith AE, Boord MS, Keage HAD. Cognitive outcomes following coronary artery bypass grafting: A systematic review and meta-analysis of 91,829 patients. Int J Cardiol 2019; 289:43-49. [PMID: 31078353 PMCID: PMC6548308 DOI: 10.1016/j.ijcard.2019.04.065] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 03/12/2019] [Accepted: 04/23/2019] [Indexed: 02/08/2023]
Abstract
Background Cognitive impairments, including delirium, are common after coronary artery bypass grafting (CABG) surgery, as described in over three decades of research. Our aim was to pool estimates across the literature for the first-time, relative to time (from pre- to post-CABG) and diagnosis (cognitive impairment, delirium and dementia). Methods A systematic search of four databases was undertaken. 215 studies incorporating data from 91,829 patients were used to estimate the prevalence of cognitive impairments pre- and post-CABG, including delirium and dementia post-CABG, using random effects meta-analyses. Results Pre-surgical cognitive impairment was seen in 19% of patients. Post-operatively, cognitive impairment was seen in around 43% of patients acutely; this resolved to 19% at 4–6 months and then increased to 25% of patients between 6-months to 1-year post-operatively. In the long term, between 1 and 5-years post-operatively, cognitive impairment increased and was seen in nearly 40% of patients. Post-operative delirium was apparent in 18% of CABG patients which increased to 24% when a diagnostic instrument was utilized alongside clinical criteria. Dementia was present in 7% of patients 5–7 years post-surgery. Conclusion The results of this meta-analysis demonstrate that cognitive impairment and delirium are major issues in CABG patients which require specific attention. It is imperative that appropriate methods for investigating cognitive impairment, and screening for delirium using a diagnostic instrument, occur in both pre-and post-CABG settings. This meta-analysis pooled results of 91,829 patients, including 215 studies. Cognitive impairment and delirium are seen in up to 40% of CABG patients. Appropriate methods investigating cognitive impairment are crucial post-CABG. Appropriate methods of screening for delirium are crucial post-CABG.
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Affiliation(s)
- Danielle Greaves
- Cognitive Ageing and Impairment Neurosciences Laboratory, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia.
| | - Peter J Psaltis
- Vascular Research Centre, Heart Health Theme, South Australian Health and Medical Research Institute, Adelaide, Australia and Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Tyler J Ross
- Cognitive Ageing and Impairment Neurosciences Laboratory, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing Unit at University College London, London, United Kingdom
| | - Ashleigh E Smith
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, University of South Australia, Adelaide, Australia
| | - Monique S Boord
- Cognitive Ageing and Impairment Neurosciences Laboratory, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
| | - Hannah A D Keage
- Cognitive Ageing and Impairment Neurosciences Laboratory, School of Psychology, Social Work and Social Policy, University of South Australia, Adelaide, Australia
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Giovannetti T, Price CC, Fanning M, Messé S, Ratcliffe SJ, Lyon A, Kasner SE, Seidel G, Bavaria JE, Szeto WY, Hargrove WC, Acker MA, Floyd TF. Cognition and Cerebral Infarction in Older Adults After Surgical Aortic Valve Replacement. Ann Thorac Surg 2018; 107:787-794. [PMID: 30423336 DOI: 10.1016/j.athoracsur.2018.09.057] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 08/27/2018] [Accepted: 09/18/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Aortic valve replacement (AVR) for calcific aortic stenosis is associated with high rates of perioperative stroke and silent cerebral infarcts on diffusion-weighted magnetic resonance imaging (MRI), but cognitive outcomes in elderly AVR patients compared with individuals with cardiac disease who do not undergo surgery are uncertain. METHODS One hundred ninety AVR patients (mean age 76 ± 6 years) and 198 non-surgical participants with cardiovascular disease (mean age 74 ± 6 years) completed comprehensive cognitive testing at baseline (preoperatively) and 4 to 6 weeks and 1 year postoperatively. Surgical participants also completed perioperative stroke evaluations, including postoperative brain MRI. Mixed model analyses and reliable change scores examined cognitive outcomes. Stroke outcomes were evaluated in participants with and without postoperative cognitive dysfunction. RESULTS From reliable change scores, only 12.4% of the surgical group demonstrated postoperative cognitive dysfunction at 4 to 6 weeks and 7.5% at 1 year. Although the surgical group had statistically significantly lower scores in working memory/inhibition 4 to 6 weeks after surgery, the groups did not differ at 1 year. In surgical participants, postoperative cognitive dysfunction was associated with a greater number (p < 0.01) and larger total volume (p < 0.01) of acute cerebral infarcts on MRI. CONCLUSIONS In high-risk, aged participants undergoing surgical AVR for aortic stenosis, postoperative cognitive dysfunction was surprisingly limited and was resolved by 1 year in most. Postoperative cognitive dysfunction at 4 to 6 weeks was associated with more and larger acute cerebral infarcts.
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Affiliation(s)
- Tania Giovannetti
- Department of Psychology, Temple University, Philadelphia, Pennsylvania.
| | - Catherine C Price
- Department of Clinical and Health Psychology, University of Florida College of Medicine, Gainesville, Florida; Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
| | - Molly Fanning
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Steven Messé
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah J Ratcliffe
- Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Abigail Lyon
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gregory Seidel
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wilson Y Szeto
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - W Clarke Hargrove
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas F Floyd
- Department of Anesthesiology and Pain Management, University of Texas Southwestern, Dallas, Texas; Department of Cardiovascular Surgery, University of Texas Southwestern, Dallas, Texas; Department of Radiology, University of Texas Southwestern, Dallas, Texas
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Aligning nomenclature for cognitive changes associated with anaesthesia and surgery with broader diagnostic classifications of non-surgical populations: a needed first step. Br J Anaesth 2018; 121:991-993. [PMID: 30336869 DOI: 10.1016/j.bja.2017.12.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/15/2017] [Indexed: 11/24/2022] Open
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Abstract
Frailty is a state of decreased physiologic reserve and resistance to stressors. Its prevalence increases with age and is estimated to be 26% in those aged above 85 years. As the population ages, frailty will be increasingly seen in surgical patients receiving anesthesia. Here, we evaluate the instruments which have been developed and validated for measuring frailty in surgical patients and summarize frailty tools used in 110 studies linking frailty status with adverse outcomes post-surgery. Frail older people are vulnerable to geriatric syndromes, and complications such as postoperative cognitive dysfunction and delirium are explored. This review also considers how frailty, with its decline of organ function, affects the metabolism of anesthetic agents and may influence the choice of anesthetic technique in an older person. Optimal perioperative care includes the identification of frailty, a multisystem and multidisciplinary evaluation preoperatively, and discussion of treatment goals and expectations. We conclude with an overview of the emerging evidence that Comprehensive Geriatric Assessment can improve postoperative outcomes and a discussion of the models of care that have been developed to improve preoperative assessment and enhance the postoperative recovery of older surgical patients.
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Affiliation(s)
- Hui-Shan Lin
- Centre for Research in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia,
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
| | - Rebecca L McBride
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Ruth E Hubbard
- Centre for Research in Geriatric Medicine, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia,
- PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, QLD, Australia,
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Pataraia E, Jung R, Aull-Watschinger S, Skhirtladze-Dworschak K, Dworschak M. Seizures After Adult Cardiac Surgery and Interventional Cardiac Procedures. J Cardiothorac Vasc Anesth 2018; 32:2323-2329. [DOI: 10.1053/j.jvca.2017.12.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Indexed: 12/29/2022]
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Abstract
Cognitive complications are common after surgery in the elderly, and with an increased number of elderly patients undergoing surgery, a potential impact of anaesthesia and surgery on long term cognition, and especially dementia would be concerning. The question whether anaesthesia and surgery in itself induce structural changes in the brain and thereby cognitive deterioration, or reveal a preexisting cognitive impairment remains unresolved. Several studies show an increased risk of reversible cognitive impairment after surgery in the elderly, but the risk of inducing dementia remains speculative. Further studies are needed to elucidate this potential association. Meanwhile, elderly frail patients need to be closely followed including preoperative cognitive screening, since they are at increased risk of cognitive deterioration after surgery and discharge.
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Affiliation(s)
- Jacob Steinmetz
- University of Copenhagen, Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark.
| | - Lars Simon Rasmussen
- University of Copenhagen, Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen, Denmark
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Aranake-Chrisinger A, Cheng JZ, Muench MR, Tang R, Mickle A, Maybrier H, Lin N, Wildes T, Lenze E, Avidan MS. Ability of postoperative delirium to predict intermediate-term postoperative cognitive function in patients undergoing elective surgery at an academic medical centre: protocol for a prospective cohort study. BMJ Open 2018; 8:e017079. [PMID: 29550773 PMCID: PMC5875681 DOI: 10.1136/bmjopen-2017-017079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication in elderly patients, characterised by a fluctuating course of altered consciousness, disordered thinking and inattention. Preliminary research has linked POD with persistent cognitive impairment and decreased quality of life. However, these findings maybe confounded by patient comorbidities, postoperative complications and frailty. Our objective is to determine whether POD is an independent risk factor for persistent impairments in attention and executive function after elective surgery. Our central hypothesis is that patients with POD are more likely to have declines in cognition and quality of life 1 year after surgery compared with patients without POD. We aim to clarify whether these associations are independent of potentially confounding factors. We will also explore the association between POD and incident dementia. METHODS AND ANALYSIS This study will recruit 200 patients from the ongoing Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) study. Patients who live ≤45 miles from the study centre or have a planned visit to the centre 10-16 months postoperatively will be eligible. Patients with POD, measured by the Confusion Assessment Method, will be compared with patients without delirium. The primary outcome of cognitive function and secondary outcomes of quality of life and incident dementia will be compared between cohorts. Cognition will be measured by Trails A and B and Stroop Color and Word Test, quality of life with Veteran's RAND 12-item Health Survey and incident dementia with the Short Blessed Test. Multivariable regression analyses and a Cox proportional hazards analysis will be performed. All results will be reported with 95% CIs and α=0.05. ETHICS AND DISSEMINATION The study has been approved by the Washington University in St. Louis Institutional Review Board (IRB no 201601099). Plans for dissemination include scientific publications and presentations at scientific conferences. TRIAL REGISTRATION NUMBER NCT02241655.
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Affiliation(s)
- Amrita Aranake-Chrisinger
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Jenny Zhao Cheng
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Maxwell R Muench
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
- Kirksville College of Osteopathic Medicine, Kirksville, Missouri, USA
| | - Rose Tang
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Angela Mickle
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Hannah Maybrier
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Nan Lin
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
- Division of Biostatistics, Department of Mathematics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Troy Wildes
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Eric Lenze
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
| | - Michael Simon Avidan
- Department of Anesthesiology, Washington University School of Medicine in St. Louis, Saint Louis, Missouri, USA
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Affiliation(s)
- Rebecca F. Gottesman
- Departments of Neurology and Epidemiology, Johns Hopkins University, Baltimore, MD
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23
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Hood R, Budd A, Sorond FA, Hogue CW. Peri-operative neurological complications. Anaesthesia 2018; 73 Suppl 1:67-75. [DOI: 10.1111/anae.14142] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2017] [Indexed: 11/27/2022]
Affiliation(s)
- R. Hood
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - A. Budd
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - F. A. Sorond
- Department of Neurology; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - C. W. Hogue
- Department of Anesthesiology; Northwestern University Feinberg School of Medicine; Chicago IL USA
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Culley DJ, Flaherty D, Reddy S, Fahey MC, Rudolph J, Huang CC, Liu X, Xie Z, Bader AM, Hyman BT, Blacker D, Crosby G. Preoperative Cognitive Stratification of Older Elective Surgical Patients: A Cross-Sectional Study. Anesth Analg 2017; 123:186-92. [PMID: 27028776 DOI: 10.1213/ane.0000000000001277] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Preexisting cognitive impairment is emerging as a predictor of poor postoperative outcomes in seniors. We hypothesized that preoperative cognitive screening can be performed in a busy preadmission evaluation center and that cognitive impairment is prevalent in elective geriatric surgical patients. METHODS We approached 311 patients aged 65 years and older presenting for preoperative evaluation before elective surgery in a prospective, observational, single-center study. Forty-eight patients were ineligible, and 63 declined. The remaining 200 were randomly assigned to the Mini-Cog (N =100) or Clock-in-the-Box [CIB; N = 100)] test. Study staff administered the test in a quiet room, and 2 investigators scored the tests independently. Probable cognitive impairment was defined as a Mini-Cog ≤ 2 or a CIB ≤ 5. RESULTS The age of consenting patients was 73.7 ± 6.4 (mean ± SD) years. There were no significant differences between patients randomly assigned to the Mini-Cog and CIB test in age, weight, gender, education, ASA physical status, or Charlston Index. Overall, 23% of patients met criteria for probable cognitive impairment, and prevalence was virtually identical regardless of the test used; 22% screened with the Mini-Cog and 23% screened with the CIB scored as having probable cognitive impairment (P = 1.0 by χ analysis). Both tests had good interrater reliability (Krippendroff α = 0.86 [0.72-0.93] for Mini-Cog and 1 for CIB). CONCLUSIONS Preoperative cognitive screening is feasible in most geriatric elective surgical patients and reveals a substantial prevalence of probable cognitive impairment in this population.
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Affiliation(s)
- Deborah J Culley
- From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; †University of Cincinnati College of Medicine, Cincinnati, Ohio; ‡ Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; §Department of Anesthesiology, Perioperative and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ∥Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; ¶ Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School and Harvard School of Public Health, Boston, Massachusetts; and #Department of Epidemiology, Harvard School of Public Health, Boston, Massachusetts
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Hughes CG, Patel MB, Jackson JC, Girard TD, Geevarghese SK, Norman BC, L.Thompson J, Chandrasekhar R, Brummel NE, May AK, Elstad MR, Wasserstein ML, Goodman RB, Moons KG, Dittus RS, Ely EW, Pandharipande PP. Surgery and Anesthesia Exposure Is Not a Risk Factor for Cognitive Impairment After Major Noncardiac Surgery and Critical Illness. Ann Surg 2017; 265:1126-1133. [PMID: 27433893 PMCID: PMC5856253 DOI: 10.1097/sla.0000000000001885] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to determine whether surgery and anesthesia exposure is an independent risk factor for cognitive impairment after major noncardiac surgery associated with critical illness. SUMMARY OF BACKGROUND DATA Postoperative cognitive impairment is a prevalent individual and public health problem. Data are inconclusive as to whether this impairment is attributable to surgery and anesthesia exposure versus patients' baseline factors and hospital course. METHODS In a multicenter prospective cohort study, we enrolled ICU patients with major noncardiac surgery during hospital admission and with nonsurgical medical illness. At 3 and 12 months, we assessed survivors' global cognitive function with the Repeatable Battery for the Assessment of Neuropsychological Status and executive function with the Trail Making Test, Part B. We performed multivariable linear regression to study the independent association of surgery/anesthesia exposure with cognitive outcomes, adjusting initially for baseline covariates and subsequently for in-hospital covariates. RESULTS We enrolled 1040 patients, 402 (39%) with surgery/anesthesia exposure. Median global cognition scores were similar in patients with surgery/anesthesia exposure compared with those without exposure at 3 months (79 vs 80) and 12 months (82 vs 82). Median executive function scores were also similar at 3 months (41 vs 40) and 12 months (43 vs 42). Surgery/anesthesia exposure was not associated with worse global cognition or executive function at 3 or 12 months in models incorporating baseline or in-hospital covariates (P > 0.2). Higher baseline education level was associated with better global cognition at 3 and 12 months (P < 0.001), and longer in-hospital delirium duration was associated with worse global cognition (P < 0.02) and executive function (P < 0.01) at 3 and 12 months. CONCLUSIONS Cognitive impairment after major noncardiac surgery and critical illness is not associated with the surgery and anesthesia exposure but is predicted by baseline education level and in-hospital delirium.
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Affiliation(s)
- Christopher G. Hughes
- Department of Anesthesiology, Division of Anesthesiology Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Mayur B. Patel
- Section of Surgical Sciences, Departments of Surgery, Neurosurgery and Hearing and Speech Sciences, Division of Trauma and, Surgical Critical Care, and Emergency General Surgery, Vanderbilt Brain Institute, Center for Health Services Research, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - James C. Jackson
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Research Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Timothy D. Girard
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Sunil K. Geevarghese
- Depart-Department of Surgery, Radiology, and Radiological Sciences, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Brett C. Norman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jennifer L.Thompson
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Rameela Chandrasekhar
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Nathan E. Brummel
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Addison K. May
- Section of Surgical Sciences, Department of Surgery, Division of Trauma and Surgical Critical Care, and Emergency General Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark R. Elstad
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Utah School of Medicine, George E. Wahlen Department of Veterans Affairs Medical Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah
| | - Mitzi L. Wasserstein
- George E. Wahlen Department of Veterans Affairs Medical Center, Veterans Administration Salt Lake City Health Care System, Salt Lake City, Utah
| | - Richard B. Goodman
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington School of Medicine, Seattle Division, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Karel G. Moons
- Clinical Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, the Netherlands
| | - Robert S. Dittus
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - E. Wesley Ely
- Department of Medicine, Division of Pulmonary and Critical Care Medicine and Center for Health Services Research, Vanderbilt University Medical Center, Geriatric Research, Education and Clinical Center Service, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Pratik P. Pandharipande
- Departments of Anesthesiology and Surgery, Division of Anesthesiology Critical Care Medicine, Vanderbilt University Medical Center, Nashville Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee
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Neupane I, Arora RC, Rudolph JL. Cardiac surgery as a stressor and the response of the vulnerable older adult. Exp Gerontol 2017; 87:168-174. [PMID: 27125757 PMCID: PMC5081280 DOI: 10.1016/j.exger.2016.04.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 12/21/2022]
Abstract
In an aging population, recovery and restoration of function are critical to maintaining independence. Over the past 50years, there have been dramatic improvements made in cardiac surgery processes and outcomes that allow for procedures to be performed on an increasingly older population with the goal of improving function. Although improved function is possible, major surgical procedures are associated with substantial stress, which can severely impact outcomes. Past literature has identified that frail patients, who are vulnerable to the stress of surgery, are more likely to have postoperative major adverse cardiac and cerebrovascular events (OR 4.9, 95% confidence interval 1.6, 14.6). The objective of this manuscript is to examine preoperative frailty in biological, psychological, and social domains using cardiac surgery to induce stress. We systematically searched PubMed for keywords including "cardiac surgery, frailty, and aged" in addition to the biological, psychological, and social keywords. In the biological domain, we examine the association of physiological and physical vulnerabilities, as well as, the impact of comorbidities and inflammation on negative surgical outcomes. In the psychological domain, the impact of cognitive impairment, depression, and anxiety as vulnerabilities were examined. In the social domain, social structure, coping, disparities, and addiction as vulnerabilities are described. Importantly, there is substantial overlap in the domains of vulnerability. While frailty research has largely focused on discrete physical vulnerability criteria, a broader definition of frailty demonstrates that vulnerabilities in biological, psychological, and social domains can limit recovery after the stress of cardiac surgery. Identification of vulnerability in these domains can allow better understanding of the risks of cardiac surgery and tailoring of interventions to improve outcomes.
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Affiliation(s)
- Iva Neupane
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States
| | - Rakesh C Arora
- University of Manitoba, College of Medicine, Department of Surgery, Winnipeg, Manitoba, Canada
| | - James L Rudolph
- Center of Innovation in Long Term Services and Support, Providence VA Medical Center, Providence, RI, United States; Warren Alpert School of Medicine at Brown University, Providence, RI, United States.
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Sheth KN, Nourollahzadeh E. Neurologic complications of cardiac and vascular surgery. HANDBOOK OF CLINICAL NEUROLOGY 2017; 141:573-592. [PMID: 28190436 DOI: 10.1016/b978-0-444-63599-0.00031-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This chapter will provide an overview of the major neurologic complications of common cardiac and vascular surgeries, such as coronary artery bypass grafting and carotid endarterectomy. Neurologic complications after cardiac and vascular surgeries can cause significant morbidity and mortality, which can negate the beneficial effects of the intervention. Some of the complications to be discussed include ischemic and hemorrhagic stroke, seizures, delirium, cognitive dysfunction, cerebral hyperperfusion syndrome, cranial nerve injuries, and peripheral neuropathies. The severity of these complications can range from mild to lethal. The etiology of complications can include a variety of mechanisms, which can differ based on the type of cardiac or vascular surgery that is performed. Our knowledge about neuropathology, prevention, and management of surgical complications is growing and will be discussed in this chapter. It is imperative for clinicians to be familiar with these complications in order to narrow the differential diagnosis, start early management, anticipate the natural history, and improve outcomes.
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Affiliation(s)
- K N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.
| | - E Nourollahzadeh
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA
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Kratz T, Diefenbacher A. [Acute and long-term cognitive consequences of treatment on intensive care units]. DER NERVENARZT 2016; 87:246-52. [PMID: 26910259 DOI: 10.1007/s00115-016-0078-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Following treatment on the intensive care unit (ICU) patients often suffer from acute and long-term cognitive deficits. This is true for patients of all age groups but especially for elderly patients who have undergone surgery and develop postoperative delirium (POD) or postoperative cognitive decline (POCD). Both are associated with severe limitations in the quality of life and long-term outcome. OBJECTIVE Which acute and long-term cognitive effects develop in ICU survivors and how do they influence the outcome? How can POD and POCD be differentiated? METHOD A selective literature search was carried out. RESULTS Following surgery POCD can develop within days to weeks, may persist for weeks or months and can lead to problems in attentiveness even under conditions of inconspicuous consciousness. Remission is possible but may take up to more than 12 months. The POD is a phenomenon characterized by disturbances of consciousness and problems in attention, beginning acutely hours and days postoperatively, can persist for days to weeks and remission can be expected within a few days. While POD often has an organic cause, such as an infection, the pathogenesis of POCD has not been sufficiently elucidated. DISCUSSION Both POD and particularly POCD can lead to a deterioration of cognition following ICU treatment. As efficient treatment still has to be developed preventive methods, such as preoperative screening for risk factors, thorough planning of operative and anesthetic techniques and compensation of risk factors as well as providing assistance to patients, e. g. by a trained nurse should be implemented in the clinical routine more often than is presently the case.
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Affiliation(s)
- T Kratz
- Abt. für Psychiatrie, Psychotherapie und Psychosomatik, Evangelisches Krankenhaus Königin Elisabeth Herzberg gGmbH, Herzbergstr. 79, 10365, Berlin, Deutschland.
| | - A Diefenbacher
- Abt. für Psychiatrie, Psychotherapie und Psychosomatik, Evangelisches Krankenhaus Königin Elisabeth Herzberg gGmbH, Herzbergstr. 79, 10365, Berlin, Deutschland
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Bokeriya LA, Aronov DM. Russian clinical guidelines Coronary artery bypass grafting in patients with ischemic heart disease: rehabilitation and secondary prevention. ACTA ACUST UNITED AC 2016. [DOI: 10.26442/cs45210] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Melo A, Leite-Almeida H, Ferreira C, Sousa N, Pêgo JM. Exposure to Ketamine Anesthesia Affects Rat Impulsive Behavior. Front Behav Neurosci 2016; 10:226. [PMID: 27932959 PMCID: PMC5121127 DOI: 10.3389/fnbeh.2016.00226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 11/09/2016] [Indexed: 11/13/2022] Open
Abstract
Introduction: Ketamine is a general anesthetic (GA) that activates several neurotransmitter pathways in various part of the brain. The acute effects as GA are the most well-known and sought-after: to induce loss of responsiveness and to produce immobility during invasive procedures. However, there is a concern that repeated exposure might induce behavioral changes that could outlast their acute effect. Most research in this field describes how GA affects cognition and memory. Our work is to access if general anesthesia with ketamine can disrupt the motivational behavior trait, more specifically measuring impulsive behavior. Methods: Aiming to evaluate the effects of exposure to repeat anesthetic procedures with ketamine in motivational behavior, we tested animals in a paradigm of impulsive behavior, the variable delay-to-signal (VDS). In addition, accumbal and striatal medium spiny neurons morphology was assessed. Results: Our results demonstrated that previous exposure to ketamine deep-anesthesia affects inhibitory control (impulsive behavior). Specifically, ketamine exposed animals maintain a subnormal impulsive rate in the initial periods of the delays. However, in longer delays while control animals progressively refrain their premature unrewarded actions, ketamine-exposed animals show a different profile of response with higher premature unrewarded actions in the last seconds. Animals exposed to multiple ketamine anesthesia also failed to show an increase in premature unrewarded actions between the initial and final periods of 3 s delays. These behavioral alterations are paralleled by an increase in dendritic length of medium spiny neurons of the nucleus accumbens (NAc). Conclusions: This demonstrates that ketamine anesthesia acutely affects impulsive behavior. Interestingly, it also opens up the prospect of using ketamine as an agent with the ability to modulate impulsivity trait.
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Affiliation(s)
- António Melo
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal; ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Hugo Leite-Almeida
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal; ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Clara Ferreira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal; ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - Nuno Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal; ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
| | - José M Pêgo
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of MinhoBraga, Portugal; ICVS/3B's - PT Government Associate LaboratoryBraga/Guimarães, Portugal
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Abstract
Abstract
Background
Although postoperative cognitive dysfunction (POCD) is well described after coronary artery bypass graft (CABG) surgery, a major concern has been that a progressive decline in cognition will ultimately lead to dementia. Since dementia interferes with the ability to carry out daily functions, the impact has far greater ramifications than cognitive decline defined purely by a decreased ability to perform on a battery of neurocognitive tests. The authors hypothesized that early cognitive impairment measured as baseline cognitive impairment is associated with an increased risk of long-term dementia.
Methods
The authors conducted a prospective longitudinal study on 326 patients aged 55 yr and older at the time of undergoing CABG surgery. Dementia was classified by expert opinion on review of performance on the Clinical Dementia Rating Scale and several other assessment tasks. Patients were also assessed for POCD at 3 and 12 months and at 7.5 yr using a battery of neuropsychologic tests and classified using the reliable change index. Associations were assessed using univariable analysis.
Results
At 7.5 yr after CABG surgery, the prevalence of dementia was 36 of 117 patients (30.8%; 95% CI, 23 to 40). POCD was detected in 62 of 189 patients (32.8%; 95% CI, 26 to 40). Due to incomplete assessments, the majority (113 patients), but not all, were assessed for both dementia and POCD. Fourteen of 32 (44%) patients with dementia were also classified as having POCD. Preexisting cognitive impairment and peripheral vascular disease were both associated with dementia 7.5 yr after CABG surgery. POCD at both 3 (odds ratio, 3.06; 95% CI, 1.39 to 9.30) and 12 months (odds ratio, 4.74; 95% CI, 1.63 to 13.77) was associated with an increased risk of mortality by 7.5 yr.
Conclusions
The prevalence of dementia at 7.5 yr after CABG surgery is greatly increased compared to population prevalence. Impaired cognition before surgery or the presence of cardiovascular disease may contribute to the high prevalence.
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Rappold T, Laflam A, Hori D, Brown C, Brandt J, Mintz CD, Sieber F, Gottschalk A, Yenokyan G, Everett A, Hogue CW. Evidence of an association between brain cellular injury and cognitive decline after non-cardiac surgery. Br J Anaesth 2016; 116:83-9. [PMID: 26675953 DOI: 10.1093/bja/aev415] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is common after non-cardiac surgery, but the mechanism is unclear. We hypothesized that decrements in cognition 1 month after non-cardiac surgery would be associated with evidence of brain injury detected by elevation of plasma concentrations of S100β, neuron-specific enolase (NSE), and/or the brain-specific protein glial fibrillary acid protein (GFAP). METHODS One hundred and forty-nine patients undergoing shoulder surgery underwent neuropsychological testing before and then 1 month after surgery. Plasma was collected before and after anaesthesia. We determined the relationship between plasma biomarker concentrations and individual neuropsychological test results and a composite cognitive functioning score (mean Z-score). RESULTS POCD (≥-1.5 sd decrement in Z-score from baseline) was present in 10.1% of patients 1 month after surgery. There was a negative relationship between higher plasma GFAP concentrations and lower postoperative composite Z-scores {estimated slope=-0.14 [95% confidence interval (CI) -0.24 to -0.04], P=0.005} and change from baseline in postoperative scores on the Rey Complex Figure Test copy trial (P=0.021), delayed recall trial (P=0.010), and the Symbol Digit Modalities Test (P=0.004) after adjustment for age, sex, history of hypertension and diabetes. A similar relationship was not observed with S100β or NSE concentrations. CONCLUSIONS Decline in cognition 1 month after shoulder surgery is associated with brain cellular injury as demonstrated by elevated plasma GFAP concentrations.
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Affiliation(s)
- T Rappold
- Medical Student, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Laflam
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D Hori
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - C Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - J Brandt
- Departments of Psychiatry and Behavioral Sciences and Neurology, Johns Hopkins University School of Medicine and the Department of Mental Health, Bloomberg School of Public Health, Baltimore, MD, USA
| | - C D Mintz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - F Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A Gottschalk
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - G Yenokyan
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - A Everett
- Department of Pediatrics, Johns Hopkins University School of Medicine, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - C W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, 1800 Orleans, Zayed 6208B, Baltimore, MD 21287, USA
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Liebert AD, Chow RT, Bicknell BT, Varigos E. Neuroprotective Effects Against POCD by Photobiomodulation: Evidence from Assembly/Disassembly of the Cytoskeleton. J Exp Neurosci 2016; 10:1-19. [PMID: 26848276 PMCID: PMC4737522 DOI: 10.4137/jen.s33444] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2015] [Revised: 12/09/2015] [Accepted: 12/15/2015] [Indexed: 02/07/2023] Open
Abstract
Postoperative cognitive dysfunction (POCD) is a decline in memory following anaesthesia and surgery in elderly patients. While often reversible, it consumes medical resources, compromises patient well-being, and possibly accelerates progression into Alzheimer's disease. Anesthetics have been implicated in POCD, as has neuroinflammation, as indicated by cytokine inflammatory markers. Photobiomodulation (PBM) is an effective treatment for a number of conditions, including inflammation. PBM also has a direct effect on microtubule disassembly in neurons with the formation of small, reversible varicosities, which cause neural blockade and alleviation of pain symptoms. This mimics endogenously formed varicosities that are neuroprotective against damage, toxins, and the formation of larger, destructive varicosities and focal swellings. It is proposed that PBM may be effective as a preconditioning treatment against POCD; similar to the PBM treatment, protective and abscopal effects that have been demonstrated in experimental models of macular degeneration, neurological, and cardiac conditions.
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Affiliation(s)
| | - Roberta T. Chow
- Brain and Mind Institute, University of Sydney, Sydney, NSW, Australia
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Vascular Dementia and Cognitive Impairment. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00017-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Berger M, Nadler JW, Browndyke J, Terrando N, Ponnusamy V, Cohen HJ, Whitson HE, Mathew JP. Postoperative Cognitive Dysfunction: Minding the Gaps in Our Knowledge of a Common Postoperative Complication in the Elderly. Anesthesiol Clin 2015; 33:517-50. [PMID: 26315636 DOI: 10.1016/j.anclin.2015.05.008] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Postoperative cognitive dysfunction (POCD) is a common complication associated with significant morbidity and mortality in elderly patients. There is much interest in and controversy about POCD, reflected partly in the increasing number of articles published on POCD recently. Recent work suggests surgery may also be associated with cognitive improvement in some patients, termed postoperative cognitive improvement (POCI). As the number of surgeries performed worldwide approaches 250 million per year, optimizing postoperative cognitive function and preventing/treating POCD are major public health issues. In this article, we review the literature on POCD and POCI, and discuss current research challenges in this area.
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Affiliation(s)
- Miles Berger
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA.
| | - Jacob W Nadler
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Jeffrey Browndyke
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Niccolo Terrando
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Vikram Ponnusamy
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Harvey Jay Cohen
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Heather E Whitson
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Duke South, Orange Zone, Room 4317, Durham, NC 27710, USA
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Preexisting Cognitive Impairment Is Associated with Postoperative Cognitive Dysfunction after Hip Joint Replacement Surgery. Anesthesiology 2015; 122:1224-34. [DOI: 10.1097/aln.0000000000000671] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Background:
This study investigated the prevalence of cognitive impairment in elderly noncardiac surgery patients and any association between preoperative cognitive impairment and postoperative cognitive dysfunction (POCD). Additionally, the incidence of cognitive decline at 12 months after surgery was identified.
Methods:
Three hundred patients for hip joint replacement and 51 nonsurgical controls aged 60 yr or older were studied in a prospective observational clinical trial. All study participants and controls completed a battery of eight neuropsychological tests before surgery and at 7 days, 3 months, and 12 months afterwards. Preoperative cognitive status was assessed using preexisting cognitive impairment (PreCI) defined as a decline of at least 2 SD on two or more of seven neuropsychological tests compared to population norms. POCD and cognitive decline were assessed using the reliable change index utilizing the results of the control group.
Results:
PreCI was classified in 96 of 300 (32%) patients (95% CI, 23 to 43%). After surgery, 49 of 286 (17%) patients (95% CI, 13 to 22%) and 27 of 284 (10%) patients (95% CI, 6 to 13%) demonstrated POCD at 7 days and 3 months, respectively, while 7 of 271 (3%) patients (95% CI, 1 to 4%) demonstrated cognitive decline at 12 months. Patients with PreCI had a significantly increased incidence of POCD at 7 days and 3 months and cognitive decline at 12 months.
Conclusions:
Patients with PreCI have an increased incidence of POCD and cognitive decline. PreCI is a good predictor of subsequent POCD and cognitive decline. The incidence of cognitive decline after 12 months in this group of patients is low.
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Rundshagen I. Postoperative cognitive dysfunction. DEUTSCHES ARZTEBLATT INTERNATIONAL 2015; 111:119-25. [PMID: 24622758 DOI: 10.3238/arztebl.2014.0119] [Citation(s) in RCA: 137] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Revised: 01/07/2014] [Accepted: 01/07/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND Older patients in particular are vulnerable to memory disturbances and other types of cognitive impairment after surgical operations. In one study, roughly 12% of patients over age 60 had postoperative cognitive dysfunction (POCD) three months after surgery. This is an important issue in perioperative care as extensive surgery on older patients becomes more common. METHOD Selective review of the literature. RESULTS POCD is usually transient. It is diagnosed by comparing pre- and postoperative findings on psychometric tests. Its pathogenesis is multifactorial, with the immune response to surgery probably acting as a trigger. Factors that elevate the risk of POCD include old age, pre-existing cerebral, cardiac, and vascular disease, alcohol abuse, low educational level, and intra- and postoperative complications. The findings of multiple randomized controlled trials indicate that the method of anesthesia does not play a causal role for prolonged cognitive impairment. POCD is associated with poorer recovery and increased utilization of social financial assistance. It is also associated with higher mortality (hazard ratio 1.63, 95% confidence interval 1.11-2.38). Persistent POCD enters into the differential diagnosis of dementia. CONCLUSION POCD can markedly impair postoperative recovery. The findings of pertinent studies performed to date are difficult to generalize because of heterogeneous patient groups and different measuring techniques and study designs. Further investigation is needed to determine which test instruments are best for clinical use and which preventive strategies might lessen the incidence of POCD.
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Kulik A, Ruel M, Jneid H, Ferguson TB, Hiratzka LF, Ikonomidis JS, Lopez-Jimenez F, McNallan SM, Patel M, Roger VL, Sellke FW, Sica DA, Zimmerman L. Secondary Prevention After Coronary Artery Bypass Graft Surgery. Circulation 2015; 131:927-64. [DOI: 10.1161/cir.0000000000000182] [Citation(s) in RCA: 260] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Levine DA, Davydow DS, Hough CL, Langa KM, Rogers MAM, Iwashyna TJ. Functional disability and cognitive impairment after hospitalization for myocardial infarction and stroke. Circ Cardiovasc Qual Outcomes 2014; 7:863-71. [PMID: 25387772 PMCID: PMC4241126 DOI: 10.1161/hcq.0000000000000008] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 10/15/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND We assessed the acute and long-term effect of myocardial infarction (MI) and stroke on postevent functional disability and cognition while controlling for survivors' changes in functioning over the years before the event. METHODS AND RESULTS Among participants in the nationally representative Health and Retirement Study with linked Medicare data (1998-2010), we determined within-person changes in functional limitations (basic and instrumental activities of daily living) and cognitive impairment after hospitalization for stroke (n=432) and MI (n=450), controlling for premorbid functioning using fixed-effects regression. In persons without baseline impairments, an acute MI yielded a mean acute increase of 0.41 functional limitations (95% confidence interval [CI], 0.18-0.63) with a linear increase of 0.14 limitations/year in the following decade. These increases were 0.65 limitations (95% CI, 0.07-1.23) and 0.27 limitations/year afterward for those with mild-to-moderate impairment at baseline. Stroke resulted in an acute increase of 2.07 (95% CI, 1.51-2.63) limitations because of the acute event and an increase of 0.15 limitations/year afterward for those unimpaired at baseline. There were 2.65 new limitations (95% CI, 1.86-3.44) and 0.19/year afterward for those with baseline mild-to-moderate impairment. Stroke hospitalization was associated with greater odds of moderate-to-severe cognitive impairment (odds ratio, 3.86; 95% CI, 2.10-7.11) at the time of the event, after adjustment for premorbid cognition but MI hospitalization was not. CONCLUSIONS In this population-based cohort, most MI and stroke hospitalizations were associated with significant increases in functional disability at the time of the event and in the decade afterward. Survivors of MI and stroke warrant screening for functional disability over the long-term.
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Affiliation(s)
- Deborah A Levine
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.).
| | - Dimitry S Davydow
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.)
| | - Catherine L Hough
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.)
| | - Kenneth M Langa
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.)
| | - Mary A M Rogers
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.)
| | - Theodore J Iwashyna
- From the Department of Internal Medicine (D.A.L., K.M.L., M.A.M.R., T.J.I.) and the Department of Neurology and the Stroke Program (D.A.L.), University of Michigan, Ann Arbor; Veterans Affairs Center for Clinical Management Research, Ann Arbor, MI (D.A.L., K.M.L., T.J.I.); Department of Psychiatry and Behavioral Sciences (D.S.D.) and Department of Medicine, University of Washington, Seattle (C.L.H.); and Institute for Social Research, University of Michigan, Ann Arbor (K.M.L., T.J.I.)
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Mashour GA, Woodrum DT, Avidan MS. Neurological complications of surgery and anaesthesia. Br J Anaesth 2014; 114:194-203. [PMID: 25204699 DOI: 10.1093/bja/aeu296] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Injury to the central and peripheral nervous systems is often permanent. As such, adverse neurological outcomes of surgery and anaesthesia can be devastating for patients and their families. In this article, we review the incidence, risk factors, outcomes, prevention, and treatment of a number of important neurological complications in the perioperative period.
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Affiliation(s)
- G A Mashour
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - D T Woodrum
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - M S Avidan
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Escallier KE, Nadelson MR, Zhou D, Avidan MS. Monitoring the brain: processed electroencephalogram and peri‐operative outcomes. Anaesthesia 2014; 69:899-910. [DOI: 10.1111/anae.12711] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2014] [Indexed: 11/29/2022]
Affiliation(s)
- K. E. Escallier
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. R. Nadelson
- Washington University School of Medicine Saint Louis Missouri USA
| | - D. Zhou
- Washington University School of Medicine Saint Louis Missouri USA
| | - M. S. Avidan
- Washington University School of Medicine Saint Louis Missouri USA
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Inflammatory Response in Patients under Coronary Artery Bypass Grafting Surgery and Clinical Implications: A Review of the Relevance of Dexmedetomidine Use. ACTA ACUST UNITED AC 2014. [DOI: 10.1155/2014/905238] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Despite the fact that coronary artery bypass grafting surgery (CABG) with cardiopulmonary bypass (CPB) prolongs life and reduces symptoms in patients with severe coronary artery diseases, these benefits are accompanied by increased risks. Morbidity associated with cardiopulmonary bypass can be attributed to the generalized inflammatory response induced by blood-xenosurfaces interactions during extracorporeal circulation and the ischemia/reperfusion implications, including exacerbated inflammatory response resembling the systemic inflammatory response syndrome (SIRS). The use of specific anesthetic agents with anti-inflammatory activity can modulate the deleterious inflammatory response. Consequently, anti-inflammatory anesthetics may accelerate postoperative recovery and better outcomes than classical anesthetics. It is known that the stress response to surgery can be attenuated by sympatholytic effects caused by activation of central (α-)2-adrenergic receptor, leading to reductions in blood pressure and heart rate, and more recently, that they can have anti-inflammatory properties. This paper discusses the clinical significance of the dexmedetomidine use, a selective (α-)2-adrenergic agonist, as a coadjuvant in general anesthesia. Actually, dexmedetomidine use is not in anesthetic routine, but this drug can be considered a particularly promising agent in perioperative multiple organ protection.
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Nadelson M, Sanders R, Avidan M. Perioperative cognitive trajectory in adults. Br J Anaesth 2014; 112:440-51. [DOI: 10.1093/bja/aet420] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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Uysal S, Reich DL. Neurocognitive Outcomes of Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:958-71. [DOI: 10.1053/j.jvca.2012.11.021] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Indexed: 11/11/2022]
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Klinger RY, James OG, Wong TZ, Newman MF, Doraiswamy PM, Mathew JP. Cortical β-amyloid levels and neurocognitive performance after cardiac surgery. BMJ Open 2013; 3:e003669. [PMID: 24056491 PMCID: PMC3780320 DOI: 10.1136/bmjopen-2013-003669] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
INTRODUCTION Neurological and neurocognitive dysfunction occurs frequently in the large number of increasingly elderly patients undergoing cardiac surgery every year. Perioperative cognitive deficits have been shown to persist after discharge and up to several years after surgery. More importantly, perioperative cognitive decline is predictive of long-term cognitive dysfunction, reduced quality of life and increased mortality. The proposed mechanisms to explain the cognitive decline associated with cardiac surgery include the neurotoxic accumulation of β-amyloid. This study will be the first to provide molecular imaging to assess the relationship between neocortical β-amyloid deposition and postoperative cognitive dysfunction. METHODS AND ANALYSIS 40 patients providing informed consent for participation in this Institutional Review Board-approved study and undergoing cardiac (coronary artery bypass graft (CABG), valve or CABG+valve) surgery with cardiopulmonary bypass will be enrolled based on defined inclusion and exclusion criteria. At 6 weeks after surgery, participants will undergo (18)F-florbetapir positron emission tomography imaging to assess neocortical β-amyloid burden along with a standard neurocognitive battery and blood testing for apolipoprotein E ε-4 genotype. RESULTS The results will be compared to those of 40 elderly controls and 40 elderly patients with mild cognitive impairment who have previously completed (18)F-florbetapir imaging. ETHICS AND DISSEMINATION This study has been approved by the Duke University Institutional Review Board. The results will provide novel mechanistic insights into postoperative cognitive dysfunction that will inform future studies into potential treatments or preventative therapies of long-term cognitive decline after cardiac surgery.
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Affiliation(s)
- Rebecca Y Klinger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Olga G James
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Terence Z Wong
- Department of Radiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - P Murali Doraiswamy
- Department of Psychiatry, Duke University Medical Center, Durham, North Carolina, USA
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
- Duke Institute for Brain Sciences, Duke University Medical Center, Durham, North Carolina, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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Cerebral dysfunction after coronary artery bypass surgery. J Anesth 2013; 28:242-8. [DOI: 10.1007/s00540-013-1699-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Accepted: 08/08/2013] [Indexed: 01/01/2023]
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Davydow DS, Hough CL, Levine DA, Langa KM, Iwashyna TJ. Functional disability, cognitive impairment, and depression after hospitalization for pneumonia. Am J Med 2013; 126:615-24.e5. [PMID: 23499326 PMCID: PMC3690157 DOI: 10.1016/j.amjmed.2012.12.006] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 11/22/2012] [Accepted: 12/10/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE The study objective was to examine whether hospitalization for pneumonia is associated with functional decline, cognitive impairment, and depression, and to compare this impairment with that seen after known disabling conditions, such as myocardial infarction or stroke. METHODS We used data from a prospective cohort of 1434 adults aged more than 50 years who survived 1711 hospitalizations for pneumonia, myocardial infarction, or stroke drawn from the Health and Retirement Study (1998-2010). Main outcome measures included the number of Activities and Instrumental Activities of Daily Living requiring assistance and the presence of cognitive impairment and substantial depressive symptoms. RESULTS Hospitalization for pneumonia was associated with 1.01 new impairments in Activities and Instrumental Activities of Daily Living (95% confidence interval [CI], 0.71-1.32) among patients without baseline functional impairment and 0.99 new impairments in Activities and Instrumental Activities of Daily Living (95% CI, 0.57-1.41) among those with mild-to-moderate baseline limitations, as well as moderate-to-severe cognitive impairment (odds ratio, 2.46; 95% CI, 1.60-3.79) and substantial depressive symptoms (odds ratio, 1.63; 95% CI, 1.06-2.51). Patients without baseline functional impairment who survived pneumonia hospitalization had more subsequent impairments in Activities and Instrumental Activities of Daily Living than those who survived myocardial infarction hospitalization. There were no significant differences in subsequent moderate-to-severe cognitive impairment or substantial depressive symptoms between patients who survived myocardial infarction or stroke and those who survived pneumonia. CONCLUSIONS Hospitalization for pneumonia in older adults is associated with subsequent functional and cognitive impairment. Improved pneumonia prevention and interventions to ameliorate adverse sequelae during and after hospitalization may improve outcomes.
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Affiliation(s)
- Dimitry S Davydow
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA 98104, USA.
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Evered L. Dissecting the possible influences of anesthesia and surgery on Alzheimer’s disease. Neurodegener Dis Manag 2013. [DOI: 10.2217/nmt.13.8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
SUMMARY Alzheimer’s disease (AD) is a neurodegenerative disease with late onset leading to significant morbidity and, ultimately, mortality. The prevalence of dementia in developed countries for individuals aged 65 years or over is approximately 10% currently, and the number of people with dementia is projected to increase by 350% by 2050. Older people frequently require anesthesia and surgery, such that by 2050 it is anticipated that 50% of all anesthetics will be administered to people aged 65 years or over. Anesthesia is known to be associated with neuropathological changes that mirror AD neuropathology in animal studies, and also with clinical cognitive changes known as postoperative cognitive dysfunction. This article will consider the evidence to date and whether we are able to dissect the possible influences of anesthesia and surgery. Identifying associations between postoperative cognitive dysfunction, dementia and AD is essential for developing strategies that will limit injury, and defer or prevent this disease. As a first step, preoperative cognitive assessment as part of routine perioperative management should become routine practice.
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Affiliation(s)
- Lisbeth Evered
- Centre for Anaesthesia & Cognitive Function, Department of Anaesthesia, St Vincent’s Health, PO Box 2900, 3065 Fitzroy Victoria, Australia
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Bruce KM, Yelland GW, Smith JA, Robinson SR. Recovery of Cognitive Function After Coronary Artery Bypass Graft Operations. Ann Thorac Surg 2013; 95:1306-13. [DOI: 10.1016/j.athoracsur.2012.11.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 11/07/2012] [Accepted: 11/12/2012] [Indexed: 11/16/2022]
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