Prevalence and severity of cognitive dysfunction in patients referred for transcatheter aortic valve implantation (TAVI): clinical and cognitive impact at 1 year

Establishment and clinical impacts of decision-support system for older patients with aortic valve stenosis: A retrospective observational study

OBJECTIVES

Treatment decisions for severe aortic stenosis (AS) are complex, since there are two active and comparable options: transcatheter aortic valve implantation and surgical aortic valve replacement. The disease predominantly affects older individuals, who are frequently comorbid with from cognitive impairment. This study aimed to establish a screening-triggered system to assess the decision-making capacity of patients with AS, support their decision-making, and facilitate referrals to specialists when necessary.

METHODS

This is a retrospective pre-post observational study. Relevant healthcare professionals were trained to assess and support patients' decision-making capacities.

RESULTS

Subtotals of 203 and 244 patients were enrolled before and after the implementation of the system, respectively. The requests for decision-making support significantly increased (from 1.5 % to 14.8 % of the patients). 11.5 % of the patients were identified as with declined decision-making capacity. The proportion of patients who received active treatments for AS significantly decreased from 95.0 % to 83.0 %. The nurses' documentation of patients' decision-making capacities significantly increased.

CONCLUSION

This screening-triggered system identified a substantial proportion of patients with declined decision-making capacity. A significant decrease in patients receiving active treatments for AS and increased documentation of patients' decision-making capacities in nursing records were observed. A future randomized controlled is warranted.

The utility of the Montreal cognitive assessment (MoCA) in detecting cognitive impairment in surgical populations - A systematic review and meta-analysis

STUDY OBJECTIVE

To determine the diagnostic accuracy of the Montreal Cognitive Assessment (MoCA) in detecting cognitive impairment (CI) and assess the association of MoCA scores with adverse postoperative outcomes in surgical populations.

DESIGN

Systematic review and meta-analysis.

SETTING

Perioperative setting.

PATIENTS

Adults undergoing elective or emergent surgery screened for CI preoperatively using the MoCA.

MEASUREMENTS

The outcomes included the diagnostic accuracy of the MoCA in screening for CI and the pooled prevalence of CI in various surgical populations. CI and its association with adverse events including delirium, hospital length-of-stay (LOS), postoperative complications, discharge destination, and mortality was determined.

MAIN RESULTS

Twenty-six studies (5059 patients, 18 non-cardiac studies, 8 cardiac studies) were included. With a MoCA cut-off score of <26, the prevalence of preoperative CI was 48% (95% CI: 41%-54%). The MoCA had 0.87 (95% CI: 0.79-0.93) sensitivity, 0.72 (95% CI: 0.62-0.80) specificity, PPV of 0.74 (95% CI: 0.65-0.81), and NPV of 0.86 (95% CI: 0.77-0.92) when validated against Petersen criteria, the Diagnostic and Statistical Manual of Mental Disorders, or the National Institute on Aging and the Alzheimer's Association criteria to identify CI. Using the MoCA as a screening tool, the LOS was 3.75 (95% CI: -0.03-7.53, P = 0.05, not significant) days longer in the CI group after non-cardiac surgeries and 3.33 (95% CI: 1.24-5.41, P < 0.002) days longer after cardiac surgeries than the non-cognitively impaired group.

CONCLUSIONS

MoCA had been validated in the surgical population. MoCA with a cut-off score of <26 was shown to have 87% sensitivity and 72% specificity in identifying CI. A positive screen in MoCA was associated with a 3-day longer hospital LOS in cardiac surgery in the CI group than in the non-CI group.