Perceived Cognitive Function and Emotional Distress Following Coronary Artery Bypass Surgery

"It's Incapacitated Me in so Many Ways": Older Adults' Lived Experience With Postoperative Symptoms at Home After Major Elective Surgery

OBJECTIVE

This qualitative study aimed to explore the challenges faced by older adults regarding the postoperative symptom experience after major elective surgery.

BACKGROUND

Although extensively studied in oncology settings, the impact of postoperative symptom burden remains largely underexplored in elective major surgery among older adults.

METHODS

We employed convenience sampling to recruit adults aged 65 years or above undergoing major elective surgery at the University of California, San Francisco. Semistructured interviews regarding the surgical experience were conducted at 1 and 3 months postoperatively. An inductive qualitative approach was used to identify emerging themes. Symptoms revealed by participants during interviews were also captured.

RESULTS

Nineteen participants completed a 1-month postoperative interview, and 17 additionally completed a 3-month interview. Three themes emerged: (1) postoperative symptoms significantly impacted valued life activities and psychosocial well-being, (2) participants felt "caught off guard" by the intensity and duration of postoperative symptoms, and (3) participants expressed the need for additional support, resources, and education on symptom management. The most frequently mentioned symptoms were postoperative pain (n=12, 63.1%), gastrointestinal discomfort (n=8, 42.1%), and anxiety/stress (n=8, 42.1%) at 1-month postsurgery compared with pain and depression (both n=6, 35.3%) at 3 months.

CONCLUSIONS

Study participants were surprised by the negative impact of postoperative symptoms on their psychosocial well-being and ability to engage in valued life activities. Symptom burden is an important patient-reported outcome that should be assessed postoperatively. Interventions to minimize postoperative symptom burden in older adults could optimize quality of life and participation in meaningful activities during surgical recovery.

Self-Reported Cognitive Function in Persons with Nonneurological Chronic Diseases: A Systematic Review

Background. Globally, one in three adults has a chronic condition. Many chronic diseases that are not neurological in nature (e.g., diabetes and heart failure) are increasingly associated with cognitive symptoms. However, the instruments used to assess cognitive symptoms in those with nonneurologic chronic illness are heterogeneous, and questions remain as to how cognitive symptoms may be related to demographic and clinical outcome variables, neurocognitive test performance, and other patient-reported outcomes. In this review, we describe associations among self-reported cognitive function, cognitive performance, and additional patient-reported outcomes as well as how cognitive symptoms are measured in nonneurologic chronic illness. Method. Multiple databases (PubMed, Medline, CINAHL, PsycInfo, EMBASE, SCOPUS, the Cochrane Library, and Academic Search Complete) were searched for studies from 1990 to 2020 that provided data on self-reported cognitive symptoms in those with nonneurological chronic conditions. Initial search yielded 304 articles, of which 32 met inclusion criteria. Quality assessment was conducted using the Critical Appraisal Skills Programme. Results. Thirty-two total studies were included: twenty cross-sectional, 10 longitudinal, and 2 randomized controlled trials. The tools used to assess self-reported cognitive function in the studies were heterogeneous: 28 unique tools were used. Thirty studies examined associations among self-reported cognitive function and other patient-reported outcomes. In 19 there were significant associations. Six studies showed no significant associations between neuropsychological tests and self-reported cognitive function; another 6 studies found a significant association. Conclusion. Tools to assess cognitive symptoms were heterogeneous. In most studies, self-reported cognitive symptoms were not correlated with neuropsychological test results, but the majority of studies found a strong association between self-reported cognitive function and other patient-reported outcomes. Implications. Consensus on measuring cognitive symptoms would facilitate cross-study comparisons and facilitate scientific progress in those with nonneurological chronic conditions. Based on these results, there is a need to establish a standardized approach for self-reported cognitive function measurement in patients with nonneurologic chronic illness.

A Preoperative Virtual Reality App for Patients Scheduled for Cardiac Catheterization: Pre–Post Questionnaire Study Examining Feasibility, Usability, and Acceptability

Background

Pre- and postoperative anxiety is a common phenomenon associated with negative postoperative outcomes. Symptoms of posttraumatic stress disorder, such as fear, nightmares, and sleep deprivation, are prevalent in approximately 30% to 50% of patients following discharge from intensive care units after cardiac surgery. Preliminary evidence suggests a promising role of virtual reality (VR) in preventing stress-related reactions using stress inoculation training. Such training enables cognitive preparation of individuals for stressful situations, thereby becoming more tolerant and resistant to stress, subsequently reducing the risk of potential negative psychological consequences. This study investigated a preoperative VR app—Pre-View—aimed at better informing and preparing patients for cardiac catheterization.

Objective

This study aims to assess the feasibility, usability, and acceptability of Pre-View in patients undergoing cardiac catheterization.

Methods

Eligible participants were adults scheduled for elective cardiac catheterization. Pre-View comprised an interactive virtual representation of the whole care process related to cardiac catheterization, from entering the hospital for admission to postprocedural stay and discharge. These processes were represented through 360° videos and interactive photos. Self-report questionnaires were completed at baseline (ie, before catheterization and after undergoing the VR experience) and after cardiac catheterization. Outcome measures included user experience and satisfaction, VR presence and immersive tendencies, and user friendliness. The perceived effectiveness was assessed exploratively.

Results

A total of 8 individuals, with a mean age of 67 (SD 7.5) years, participated in this study. Half of them underwent the VR experience at the hospital and the other half at home. Participants reported high levels of presence in the virtual environment (Presence Questionnaire score: mean 129.1, SD 13.4). The usability of Pre-View was well evaluated (System Usability Scale score: mean 89.1, SD 12.0), and patient satisfaction was high (Client Satisfaction Questionnaire score: mean 27.1, SD 3.2). Usability and satisfaction scores were higher for participants who underwent Pre-View at home versus those who underwent Pre-View at the hospital, although the latter group was significantly older; 72.8 versus 61.3, respectively. All participants reported Pre-View to be effective in terms of feeling better informed about the care process of cardiac catheterization. Most participants (7/8, 88%) reported Pre-View to be effective in terms of feeling better prepared for cardiac catheterization, acknowledging the potential of Pre-View in reducing negative psychological consequences after catheterization.

Conclusions

The results provide initial support for the feasibility and acceptability of a preoperative VR app, creating a virtual environment that supports patient education and preparation for upcoming cardiac catheterization. More studies are needed to further investigate the effects of VR as a tool to better prepare patients for medical procedures, its effectiveness in reducing negative patient outcomes (eg, anxiety, stress, and postoperative recovery outcomes), and the generalizability of effects across different settings and patient populations.

Patients' experiences of the complex trust-building process within digital cardiac rehabilitation

The development of digital solutions is becoming increasingly important in facing global challenges. Therefore, research on this topic is important in taking into account cardiac patients’ experiences of the rehabilitation process for the design of digital counseling solutions. The aim of the present qualitative study was to explore the different meanings that patients give to the rehabilitation process using a Glaserian grounded theory (GT) approach. Qualitative interviews were conducted with 30 participants from a rehabilitation center in Finland. The findings indicated a “complex trust-building process” core category comprising five categories of trust-building in rehabilitation: feeling that one has hit rock bottom, facing and coping in a crosscurrent, understanding together as a peer group, moving toward a healthier lifestyle with technology, and finding self-awareness. The complex process of trust-building involved interactions among emotion, cognition, and acceptance and support processes. Therefore, digital rehabilitation should be incorporated into counseling based on patients’ psychosocial, physical and emotional needs to help patients become aware of their own feelings and thoughts during the rehabilitation process.

Postoperative Cognitive Dysfunction in Indian Patients Undergoing Total Knee Replacement Under Spinal Anesthesia

Introduction

Total knee replacement is a common surgical procedure in the elderly. The number of surgeries has increased owing to the increasing life expectancy of the population and better functional outcomes postsurgery. Postoperative cognitive dysfunction (POCD) is an identified entity postsurgery in elderly but most of the studies have been on patients undergoing cardiac and other nonorthopaedic surgeries. The studies have shown variable incidence due to selection bias. We studied the incidence and probable predictive factors of POCD in elderly Indian population undergoing total knee replacement under spinal anesthesia.

Materials and Methods

We designed a prospective, observational study at a single center including patients above 60 years of age undergoing total knee replacement under spinal anesthesia. Preoperative mini-mental scale examination, electrolytes, urea and creatinine levels were recorded. Postoperatively, mini mental scale evaluation (MMSE) was done 2 days postsurgery, at 3 months, 6 months, and 1 year follow-up. Laboratory values postoperatively were recorded.

Results

The average preoperative MMSE was 27 and declined to 25.4 on second postoperative day the value increased to 25.9, 26.6, and 27 at 3 months, 6 months, and 1-year follow-up, respectively. Sixty-three out of 600 patients developed POCD at second postoperative day. Forty-three patients showed recovery in subsequent visits and 20 patients had persistent dysfunction at the end of 1 year. Electrolyte imbalance, oxygen saturation, and age over 80 years were factors that showed statistically significant difference in multiple comparison analysis.

Conclusion

In our study, we have found POCD to be a definitive entity which can cause short- and long-term cognitive defect in elderly Indian population undergoing total knee replacement and electrolyte imbalance, age, and oxygen saturation were the significant factors in the patients who developed POCD.

Hypertension and Risk of Post-Operative Cognitive Dysfunction (POCD): A Systematic Review and Meta-Analysis

Background:

Post-operative cognitive dysfunction (POCD) occurs frequently after major surgery. Hypertension is well-established as a risk factor for age-related cognitive impairment, but it is unclear whether or not it also increases the risk of POCD.

Objective:

To evaluate the role of hypertension in POCD risk in a systematic review and meta-analysis.

Method:

PubMed, Ovid SP and the Cochrane Database of Systematic Reviews were searched for longitudinal studies of adults undergoing surgery with reporting of hypertension, blood pressure and/or anti-hypertensive treatment associations with POCD as relative risks or odds ratios. Fixed-effects meta-analyses were performed using Review Manager (version 5.3).

Results:

Twenty-four studies on 4317 patients (mean age 63 years) were included. None of the studies had set out to assess hypertension as a risk factor for POCD. Hypertension was used as a categorical predictor throughout and only 2 studies adjusted for potential confounders. Across all 24 studies, hypertension was not significantly associated with POCD risk (RR 1.01; 95% CI 0.93, 1.09; p=0.82), though among 8 studies with >75% males, we found hypertension associations with a 27% increased risk of POCD (RR 1.27, 95% CI 1.07, 1.49; p=0.005).

Conclusion:

Our findings do not support the hypothesis that hypertension is a risk factor for POCD. However, since none of the studies included in our analysis were hypothesis-driven and most did not adjust for potential confounders, further systematic investigations are needed to evaluate the role of hypertension in the epidemiology of POCD.

Impact of Experiencing Acute Coronary Syndrome Prior to Open Heart Surgery on Psychiatric Status

Objective

The incidence of depression and anxiety is higher in patients with acute coronary syndrome. The aim of this study is to determine whether experiencing acute coronary syndrome prior to open heart surgery affects patients in terms of depression, hopelessness, anxiety, fear of death and quality of life.

Methods

The study included 63 patients who underwent coronary bypass surgery between January 2015 and January 2016. The patients were divided into two groups: those diagnosed after acute coronary syndrome (Group 1) and those diagnosed without acute coronary syndrome (Group 2). Beck depression scale, Beck hopelessness scale, Templer death anxiety scale and death depression scale, State-Trait anxiety inventory and WHOQOL-Bref quality of life scale were applied.

Results

There was no significant difference between the two groups in terms of the total score obtained from Beck depression scale, Beck hopelessness scale - future-related emotions, loss of motivation, future-related expectations subgroups, death anxiety scale, the death depression scale, State-Trait Anxiety Inventory - social and environmental subgroups. The mental quality of life sub-scores of group 2 were significantly higher. The patients in both groups were found to be depressed and hopeless about the future. Anxiety levels were found to be significantly higher in all of the patients in both groups.

Conclusion

Acute coronary syndrome before coronary artery bypass surgery impairs more the quality of life in mental terms. But unexpectedly there are no differences in terms of depression, hopelessness, anxiety and fear of death.

Bridging the transition from hospital to home: effects of the VITAL telehealth program on recovery for CABG surgery patients and their caregivers

The purpose of this randomized trial was to determine whether coronary artery bypass graft surgery patients and their caregivers who received telehealth follow-up had greater improvements in anxiety levels from pre-surgery to 3 weeks after discharge than did those who received standard care. Secondary outcomes included changes in depressive symptoms and patients' contacts with physicians. No group differences were noted in changes in patients' anxiety and depressive symptoms, but patients in the telehealth group had fewer physician contacts (p = .04). Female caregivers in the telehealth group had greater decreases in anxiety than those in standard care (p < .001), and caregivers of both genders in the telehealth group had greater decreases in depressive symptoms (p = .03).

A systematic review of pre-operative predictors of post-operative depression and anxiety in individuals who have undergone coronary artery bypass graft surgery

In addition to the physical benefits, another important objective of coronary artery bypass graft (CABG) surgery is improvement of health-related quality of life. The aim of this systematic review is to provide an overview of the literature relating to the pre-operative prediction of post-operative depression and anxiety in individuals who have undergone CABG surgery. Forty-six studies were identified through a literature search of electronic databases conducted using explicit inclusion and exclusion criteria. The study characteristics, methodological features, and psychometric and clinical outcomes were summarised in a systematic manner. Collective appraisal of the studies indicated that symptoms of depression and anxiety exhibited after CABG surgery are best predicted by pre-operative measures of functioning in that area. Papers were inconclusive with respect to the predictive qualities of gender and age. Further research is required to clarify the predictive values of these and other factors, including pre-morbid ill health and socio-economic status. The findings of this review indicate a range of pre-operative predictors of post-operative depression and anxiety in patients with CABG. Chief among these are pre-operative depression and anxiety. These findings have clinical implications concerning the importance of pre and post-operative psychological assessment and intervention for individuals at risk of poor psychological recovery.

Symptom burden clusters and their impact on psychosocial functioning following coronary artery bypass surgery

Although there is extensive literature on symptoms experienced by patients after coronary artery bypass surgery (CABS), there is a paucity of data on symptom clusters and their impact on functional outcomes. The purpose of these descriptive, secondary analyses was to identify and describe cluster subgroups of 226 elderly CABS patients at discharge and to examine the cluster's impact on psychosocial functioning over time (baseline, 6 weeks, and 3 months) using the 36-item Medical Outcome Study Short Form subscales. Cluster analysis revealed a 3-cluster solution with low, low-moderate, and moderate symptom burden clusters. Significant differences were detected for Duke Activity Status Index (F(2,223) = 5.12, P = .007), Barnason Efficacy Expectation Scale (F(2,223) = 9.60, P < .0001), Hospital Anxiety and Depression Scale (F(2,219) = 15.14, P < .0001), and New York Heart Association classification (chi = 17.44, P = .008). Significant differences were noted on all variables between the low and moderate symptom burden clusters with differences between the low-moderate and moderate clusters for only the Barnason Efficacy Expectation Scale and the Hospital Anxiety and Depression Scale. Those in the moderate symptom burden cluster had more symptoms, anxiety, and depression along with lower self-efficacy and physiological functioning than those in the other 2 clusters. There was no interaction or simple main effects for the role-emotional or social subscales as measured by the 36-item Medical Outcome Study Short Form. There was no significant interaction for mental functioning by time and cluster (F(4,641) = .30, P = .88); however, there was a simple main effect for cluster (F(2,641) = 4.11, P = .02). Follow-up analysis indicated significant differences between the low and low-moderate clusters, indicating that those with low symptom burden had significantly better mental health functioning than those with moderate symptom burden. Findings provide a foundation of knowledge on symptom clusters in CABS populations and may be useful to clinicians to identify patients at risk for slowed or delayed recovery and for early intervention.

Neuropsychological function 5 years after cardiac surgery and the effect of psychological distress

Research has shown conflicting results with regard to the influence of depression and anxiety on neuropsychological performance following coronary artery bypass graft (CABG) surgery. Notably, the independent effects of depression and anxiety have not been examined among CABG candidates in the longer term where it is has been suggested that these patients show marked cognitive deterioration. A neuropsychological test battery and measures of psychological distress were completed by 86 CABG patients and 50 nonsurgical control participants at baseline and 6 months, whereas 75 patients and 36 controls, respectively, completed a 5-year follow-up. In CABG patients, cognitive and affective depressive symptoms were independently associated with lower and worse performance on the Boston Naming Test, Purdue Peg Board, and Digit Symbol Coding 6 months after surgery, whereas at 5-year follow-up an effect for Digit Symbol persisted, and an association was also observed for the Trail Making Test (TMT). On average, CABG patients performed worse on TMT and Digit Symbol at 6 months, whereas at 5-year follow-up their performance was worse on short-term delayed verbal recall. The results among the CABG patients did not show a consistent pattern of association between psychological distress and those neuropsychological domains that were on average significantly lower than a nonsurgical control group. The results here also support the use of nonbiased statistical methodology to document dysfunction among heterogeneous cognitive domains after CABG surgery.

Subjective memory symptoms in surgical and nonsurgical coronary artery patients: 6-year follow-up

BACKGROUND

Self-reported cognitive and memory complaints after coronary artery bypass graft (CABG) operations are common. Several studies have attempted to quantify the incidence of such complaints and to examine the relationship between subjective and objective cognitive functioning, but the etiology and longitudinal course of these self-reports remain unclear.

METHODS

Measures of subjective memory complaints were compared in two groups: 220 CABG patients and 92 nonsurgical cardiac patients at 3 months, and 1, 3, and 6 years. At 6 years, additional measures were used to quantify memory self-assessment. The frequency of subjective complaints at each time point was determined, and associations with objective cognitive performance as well as depression were examined.

RESULTS

At early (3-month or 1-year) follow-up, subjective memory complaints were reported more often by the CABG than the nonsurgical group (45.5% vs 17.0%, p < 0.0001). By 6 years, the frequency of complaints was similar (52%) in both groups. Subjective memory ratings were significantly correlated with performance on several memory tests at 6 years. This relationship was not confounded by depression.

CONCLUSIONS

Subjective memory complaints are more frequent early in follow-up in patients undergoing CABG than in controls, but are similar by 6 years. The increase in subjective complaints over time may be related to progression of underlying cerebrovascular disease. Unlike previous studies, we found that subjective memory assessments were correlated with objective performance on several memory tests. Although subjective memory complaints are more common in patients with depression, they cannot be explained by depression alone.

Cognitive complaints after mild traumatic brain injury: things are not always what they seem

OBJECTIVE

To compare nonreferred, emergency department (ED)-admitted mild traumatic brain injury (MTBI) patients with and without self-reported cognitive complaints on (1) demographic variables and injury characteristics; (2) neuropsychological test performance; (3) 12-day self-monitoring of perceived cognitive problems; and (4) emotional distress, physical functioning, and personality.

METHODS

(Neuro)psychological assessment was carried out 6 months post-injury in 79 patients out of a cohort of 618 consecutive MTBI patients aged 18-60, who attended the ED of our level I trauma centre. Cognitive complaints were assessed with the Rivermead Postconcussional Symptoms Questionnaire (RPSQ). In addition, patients monitored concentration problems and forgetfulness during 12 consecutive days.

RESULTS

Self-reported cognitive complaints were reported by 39% of the patients. These complaints were strongly related to lower educational levels, emotional distress, personality, and poorer physical functioning (especially fatigue) but not to injury characteristics. Severity of self-reported cognitive complaints was neither associated with the patients' daily observations of cognitive problems nor with outcome on a range of neuropsychological tests.

CONCLUSION

Self-reported cognitive complaints were more strongly related to premorbid traits and physical and emotional state factors than to actual cognitive impairments. In line with previous work, this suggests that treatment of emotional distress and fatigue may also reduce cognitive complaints. Cognitive outcome assessment of symptomatic MTBI patients should not be restricted to checklist ratings only, but also include a (neuro)psychological screening. In addition, daily monitoring of complaints is a useful method to gather information about the frequency and pattern of cognitive problems in daily life.

Protein S100B after cardiac surgery: an indicator of long-term anxiety?

OBJECTIVES

The aim of the study was to assess long-term state and trait anxiety in cardiac surgical risk patients.

DESIGN

Thirty two patients with serum S100B>0.3 microg/l 48 hours after cardiac surgery with cardiopulmonary bypass were matched according to age, gender, type, date and length of surgery with 35 operated patients without elevated S100B. They completed Spielberger's Anxiety Inventory (STAI).

RESULTS

Patients with elevated S100B reported more state anxiety and trait anxiety. S100B was an independent predictor of both state and trait anxiety when controlling for perioperative variables.

CONCLUSIONS

Patients with elevated S100B reported more anxiety 3-6 years after cardiac surgery. A postoperative blood sample can identify risk patients and facilitate appropriate follow-up.