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Houghton JSM, Saratzis AN, Sayers RD, Haunton VJ. New Horizons in Peripheral Artery Disease. Age Ageing 2024; 53:afae114. [PMID: 38877714 PMCID: PMC11178507 DOI: 10.1093/ageing/afae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Indexed: 06/16/2024] Open
Abstract
Peripheral artery disease (PAD) is the lower limb manifestation of systemic atherosclerotic disease. PAD may initially present with symptoms of intermittent claudication, whilst chronic limb-threatening ischaemia (CLTI), the end stage of PAD, presents with rest pain and/or tissue loss. PAD is an age-related condition present in over 10% of those aged ≥65 in high-income countries. Guidelines regarding definition, diagnosis and staging of PAD and CLTI have been updated to reflect the changing patterns and presentations of disease given the increasing prevalence of diabetes. Recent research has changed guidelines on optimal medical therapy, with low-dose anticoagulant plus aspirin recommended in some patients. Recently published randomised trials highlight where bypass-first or endovascular-first approaches may be optimal in infra-inguinal disease. New techniques in endovascular surgery have increased minimally invasive options for ever more complex disease. Increasing recognition has been given to the complexity of patients with CLTI where a high prevalence of both frailty and cognitive impairment are present and a significant burden of multi-morbidity and polypharmacy. Despite advances in minimally invasive revascularisation techniques and reduction in amputation incidence, survival remains poor for many with CLTI. Shared decision-making is essential, and conservative management is often appropriate for older patients. There is emerging evidence of the benefit of specialist geriatric team input in the perioperative management of older patients undergoing surgery for CLTI. Recent UK guidelines now recommend screening for frailty, cognitive impairment and delirium in older vascular surgery patients as well as recommending all vascular surgery services have support and input from specialist geriatrics teams.
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Affiliation(s)
- John S M Houghton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Athanasios N Saratzis
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
| | - Rob D Sayers
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre—The Glenfield Hospital, Leicester, UK
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Goodijk D, Banning LBD, Te Velde-Keyzer CA, van Munster BC, Bakker SJL, van Leeuwen BL, Zeebregts CJ, Pol RA. Preoperative cognitive performance and its association with postoperative complications in vascular surgery patients: A prospective study. Am J Surg 2024:115784. [PMID: 38824053 DOI: 10.1016/j.amjsurg.2024.115784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 03/14/2024] [Accepted: 05/27/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND Cognitive impairment affects nearly half of vascular surgery patients, but its association with postoperative outcomes remains poorly understood. This study explores the link between preoperative cognitive performance and postoperative complications, including postoperative delirium, in vascular surgery patients. METHODS A prospective cohort study was conducted on vascular surgery patients aged ≥65. Preoperative cognitive performance was assessed using the Montreal Cognitive Assessment, and postoperative complications were evaluated using the Comprehensive Complication Index. The association was analyzed through multivariable logistic regression. RESULTS Among 110 patients (18.2 % female, mean age 73.8 ± 5.7 years), cognitive impairment was evident in 48.2 %. Of the participants, 29 (26.3 %) experienced postoperative complications, among which 11 (10 %) experienced postoperative delirium. The adjusted odds ratio for the association between cognitive performance and postoperative complications was 1.19 (95 % CI 1.02-1.38; p = 0.02). CONCLUSION Worse preoperative cognitive performance correlated with increased odds of postoperative complications and postoperative delirium in vascular surgery patients.
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Affiliation(s)
- Dagmar Goodijk
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Louise B D Banning
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Charlotte A Te Velde-Keyzer
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Barbara C van Munster
- Department of Internal Medicine, Division of Geriatric Medicine, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Stephan J L Bakker
- Department of Internal Medicine, Division of Nephrology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Barbara L van Leeuwen
- Department of Surgery, Division of Surgical Oncology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Clark J Zeebregts
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Robert A Pol
- Department of Surgery, Division of Vascular Surgery, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands.
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Banning LBD, van Munster BC, van Leeuwen BL, Trzpis M, Zeebregts CJ, Pol RA. Comparison of Various Functional Assessment Tools to Identify Older Patients Undergoing Aortic Aneurysm Repair at Risk for Postoperative Complications. Ann Vasc Surg 2024; 106:333-340. [PMID: 38815916 DOI: 10.1016/j.avsg.2024.02.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/18/2024] [Accepted: 02/28/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND To estimate whether the benefits of aortic aneurysm repair will outweigh the risks, determining individual risks is essential. This single-center prospective cohort study aimed to compare the association of functional tools with postoperative complications in older patients undergoing aortic aneurysm repair. METHODS Ninety-eight patients (≥65 years) who underwent aortic aneurysm repair were included. Four functional tools were administered: the Montreal Cognitive Assessment (MoCA); the 4-Meter Walk Test (4-MWT); handgrip strength; and the Groningen Frailty Indicator (GFI). Primary outcome was the association between all tests and 30-day postoperative complications. RESULTS After adjusting for confounders, the odds ratio for MoCA was 1.39 (95% confidence interval [CI] 0.450; 3.157; P = 0.723), for 4-MWT 0.63 (95% CI 0.242; 1.650; P = 0.348), for GFI 1.82 (95% CI 0.783; 4.323, P = 0.162), and for weak handgrip strength 4.78 (95% CI 1.338; 17.096, P = 0.016). CONCLUSIONS Weak handgrip strength is significantly associated with the development of postoperative complications after aortic aneurysm repair. This study strengthens the idea that implementing a quick screening tool for risk assessment at the outpatient clinic, such as handgrip strength, identifies patients who may benefit from preoperative enhancement with help from, for example, Comprehensive Geriatric Assessment, eventually leading to better outcomes for this patient group.
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Affiliation(s)
- Louise B D Banning
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Barbara C van Munster
- Division of Geriatric Medicine, University of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Barbara L van Leeuwen
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Monika Trzpis
- Division of Geriatric Medicine, University of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Clark J Zeebregts
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Robert A Pol
- Divisions of Vascular Surgery, Department of Surgery, Transplantation Surgery and Oncologic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Oh EC, Sridharan ND, Avgerinos ED. Cognitive function after carotid endarterectomy in asymptomatic patients. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:317-321. [PMID: 36897209 PMCID: PMC10957150 DOI: 10.23736/s0021-9509.23.12632-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Asymptomatic carotid stenosis has been shown to be associated with progressive neurocognitive decline, but the effects of carotid endarterectomy (CEA) on this are not well defined. Due to the wide heterogeneity of studies and lack of standardization in cognitive function tests and study design, there is mounting scientific evidence to support the notion that CEA is effective in reversing or slowing neurocognitive decline; however, definitive conclusions are difficult to make. Further, while the association between ACS and cognitive decline has been well document, a direct etiological role has not been established. More research is required to elucidate the relationship between asymptomatic carotid stenosis and the benefit of carotid endarterectomy and its potential protective effects regarding cognitive decline. This article aims to review current evidence in preoperative and postoperative cognitive function in asymptomatic patients with carotid stenosis undergoing CEA.
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Affiliation(s)
- Edward C Oh
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA -
| | - Natalie D Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Efthymios D Avgerinos
- Clinic of Vascular and Endovascular Surgery, Athens Medical Group, Athens, Greece
- Department of Vascular Surgery, Attikon Hospital, University of Athens, Athens, Greece
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Smith EJT, Gasper WJ, Schneider PA, Finlayson E, Walter LC, Covinsky KE, Conte MS, Iannuzzi JC. Cognitive Impairment is Common in a Veterans Affairs Population with Peripheral Arterial Disease. Ann Vasc Surg 2023; 91:210-217. [PMID: 36581154 DOI: 10.1016/j.avsg.2022.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 11/24/2022] [Accepted: 11/27/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there are little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized. METHODS Cognitive impairment screening was prospectively performed for veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of <26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment. RESULTS Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, P = 0.03), Black versus White race (94% vs. 54%, P < 0.01), hypertension (66% vs. 31%, P = 0.01), prior stroke/TIA (79% vs. 58%, P = 0.03), diabetes treated with insulin (79% vs. 58%, P = 0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, P = 0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥70 years, diabetes treated with insulin, PTSD, and Black race. CONCLUSIONS Many veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.
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Affiliation(s)
- Eric J T Smith
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Peter A Schneider
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Emily Finlayson
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Louise C Walter
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | - Ken E Covinsky
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, CA and Veterans Affairs, San Francisco, CA
| | | | - James C Iannuzzi
- Department of Surgery, Veterans Affairs, San Francisco, CA; Department of Surgery, University of California, San Francisco, San Francisco, CA.
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Yan E, He D, Rajji TK, Chung F. Cognitive impairment and its adverse outcomes in older surgical patients: an under-recognized problem! Int Anesthesiol Clin 2023; 61:23-28. [PMID: 36735463 DOI: 10.1097/aia.0000000000000392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - David He
- Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, Ontario, Canada
| | - Tarek K Rajji
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Department of Adult Neurodevelopment and Geriatric Psychiatry, Centre for Addictions and Mental Health, Toronto, Ontario, Canada
- Toronto Dementia Research Alliance, University of Toronto, Toronto, Ontario, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
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Ma JH, Liu YF, Hong H, Li CJ, Cui F, Mu DL, Wang DX. Effect of acute pain on the association between preoperative cognitive impairment and postoperative delirium: a secondary analysis of three trials. Br J Anaesth 2023; 130:e272-e280. [PMID: 35933172 DOI: 10.1016/j.bja.2022.06.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 05/25/2022] [Accepted: 06/18/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The association between preoperative cognitive impairment, postoperative pain, and postoperative delirium in older patients after noncardiac surgery is not known. METHODS This was a secondary analysis of datasets from three previous studies. Patients aged ≥55 yr who underwent elective noncardiac surgery were enrolled. Preoperative cognitive impairment was defined as Mini-Mental State Examination <27. Pain intensity with movement was assessed using an 11-point numeric rating scale at 12-h intervals during the first 72 h after surgery; time-weighted average (TWA) pain score was calculated. Primary outcome was the occurrence of delirium within the first 5 postoperative days. Mediation analysis was used to investigate the relationships between cognitive impairment, pain score, and delirium. RESULTS A total of 1497 patients were included. Prevalence of preoperative cognitive impairment was 40.3% (603/1497). Patients with cognitive impairment suffered higher TWA pain score within 72 h (4 [3-5] vs 3 [2-5], P=0.004) and more delirium within 5 days (12.9% [78/603] vs 4.9% [44/894], P<0.001) when compared with those without. Total and direct associations between cognitive impairment and delirium were (adjusted β) 8.3% (95% confidence interval [CI], 4.8-12.0%; P<0.001) and 7.8% (95% CI, 4.4-12.0%; P<0.001), respectively. A significant indirect association with acute pain was observed between cognitive impairment and delirium (adjusted β=0.4%; 95% CI, 0.1-1.0%; P=0.006), accounting for 4.9% of the total effect. CONCLUSIONS The association between preoperative cognitive impairment and delirium is significantly mediated by acute pain in patients after noncardiac surgery. Considering the small effect size, clinical significance of this mediation effect requires further investigation.
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Affiliation(s)
- Jia-Hui Ma
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Ya-Fei Liu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Hong Hong
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Chun-Jing Li
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Fan Cui
- Department of Anesthesiology, Peking University First Hospital, Beijing, China
| | - Dong-Liang Mu
- Department of Anesthesiology, Peking University First Hospital, Beijing, China.
| | - Dong-Xin Wang
- Department of Anesthesiology, Peking University First Hospital, Beijing, China; Outcomes Research Consortium, Cleveland, OH, USA
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Dawes E, Bliokas V, Hewitt L, Wilson V. Cognitive screening in persons with an amputation: A retrospective medical record audit. Prosthet Orthot Int 2022; 46:500-504. [PMID: 36037290 DOI: 10.1097/pxr.0000000000000169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 05/31/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the rate of cognitive screening undertaken with patients undergoing amputation and to determine the demographics of the sample. STUDY DESIGN Retrospective medical record audit. METHODS The medical records of a convenience sample of persons who had undergone amputation, upper and lower limb, from one local health district were reviewed. The sample date range was between January 1st, 2017, and December 31st, 2018. The incidence and type of cognitive screening were also recorded. Descriptive statistics were used to describe the results. RESULTS A total of 178 episodes of amputation care were identified during retrospective medical record auditing (mean age, 69.7 years). Thirty nine of the 178 (21.9%) episodes of care had a cognitive screening measure completed during that inpatient admission (24.2% vascular etiology and 12% nonvascular etiology). All cognitive screens were completed in persons with lower-limb amputations and were completed postoperatively. CONCLUSION Cognitive screening is not a routine part of the health care journey for patients with an amputation in this health care district.
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Affiliation(s)
- Erinn Dawes
- School of Nursing, University of Wollongong, Wollongong, Australia
- Illawarra Shoalhaven Local Health District, Port Kembla Hospital, Warrawong, Australia
| | - Vida Bliokas
- Illawarra Health and Medical Research Institute, Wollongong, Australia
- School of Psychology, University of Wollongong, Wollongong, Australia
| | - Lyndel Hewitt
- Illawarra Health and Medical Research Institute, Wollongong, Australia
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, Australia
| | - Val Wilson
- School of Nursing, University of Wollongong, Wollongong, Australia
- Illawarra Shoalhaven Local Health District, Wollongong Hospital, Wollongong, Australia
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Jansen S, Wilson C, Jasper E, Chan K. Vasculogeriatrics: embracing shared care with our colleagues in geriatric medicine should not be a threat. ANZ J Surg 2022; 92:1984-1985. [PMID: 36097431 PMCID: PMC9544075 DOI: 10.1111/ans.17785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 03/28/2022] [Accepted: 04/10/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Shirley Jansen
- Vascular Surgery, Curtin Medical School, Curtin University, Perth, Western Australia, Australia.,Department of Vascular and Endovascular Surgery, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia.,Heart and Vascular Research Institute, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Christopher Wilson
- Department Geriatric Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Emily Jasper
- Department Geriatric Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Kien Chan
- Department Geriatric Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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A systematic review of cognitive function after carotid endarterectomy in asymptomatic patients. J Vasc Surg 2022; 75:2074-2085. [PMID: 34995717 DOI: 10.1016/j.jvs.2021.12.059] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Accepted: 12/04/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Asymptomatic carotid stenosis has been associated with a progressive decline in neurocognitive function. However, the effect of carotid endarterectomy on this process is poorly understood. We aimed to evaluate pre and post-operative cognitive function changes in asymptomatic patients after carotid endarterectomy METHODS: A systematic review of the existing reports in PubMed/MEDLINE, Embase, and Cochran databases was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis statement recommendations. All original retrospective or prospective studies (including cohort, cross-sectional, case-control, pilot studies, etc.) and clinical trials that compared pre and post-operative neurocognitive function in asymptomatic patients with carotid stenosis after CEA, which were published from January 2000 to April 2021 were identified and considered eligible for inclusion in the study. RESULTS Thirteen studies (502 CEAs) comparing cognitive function changes before and after CEA were identified. In seven studies with a total number of 272 patients, a mean age range of 67.3 ± 4.8 to 76.35 years old and after follow-up ranging between 1 and 12 months, overall cognitive function improved after CEA. However, in six studies with a total sample of 230, a mean age range of 68.6 ± 6.9 to 74.4±6.1 years, and follow-up ranged from 24 hours to 3 years, showed no change or decline in overall cognitive function after procedures. CONCLUSIONS The lack of standardization of specific cognitive tests and cognitive function assessment timing after CEA does not allow for definite conclusions to be made. However, improving the brain perfusion with combination of CEA and statin therapy may be a protective strategy against cognitive function decline.
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Abcejo AS, Pai SL, Bierle DM, Jacob AK. Preoperative cognitive screening and brain health initiatives. Int Anesthesiol Clin 2022; 60:43-47. [PMID: 34897220 DOI: 10.1097/aia.0000000000000347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Arney S Abcejo
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Adam K Jacob
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
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Prevalence of preoperative cognitive impairment in older surgical patients.: A systematic review and meta-analysis. J Clin Anesth 2021; 76:110574. [PMID: 34749047 DOI: 10.1016/j.jclinane.2021.110574] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 12/23/2022]
Abstract
STUDY OBJECTIVE Older surgical patients with cognitive impairment are at an increased risk for adverse perioperative outcomes, however the prevalence of preoperative cognitive impairment is not well-established within this population. The purpose of this review is to determine the pooled prevalence of preoperative cognitive impairment in older surgical patients. DESIGN Systematic review and meta-analysis. SETTING MEDLINE (Ovid), PubMed (non-MEDLINE records only), Embase, Cochrane Central, Cochrane Database of Systematic Reviews, PsycINFO, and EMCare Nursing for relevant articles from 1946 to April 2021. PATIENTS Patients aged ≥60 years old undergoing surgery, and preoperative cognitive impairment assessed by validated cognitive assessment tools. INTERVENTIONS Preoperative assessment. MEASUREMENTS Primary outcomes were the pooled prevalence of preoperative cognitive impairment in older patients undergoing either elective (cardiac or non-cardiac) or emergency surgery. MAIN RESULTS Forty-eight studies (n = 42,498) were included. In elective non-cardiac surgeries, the pooled prevalence of unrecognized cognitive impairment was 37.0% (95% confidence interval [CI]: 30.0%, 45.0%) among 27,845 patients and diagnosed cognitive impairment was 18.0% (95% CI: 9.0%, 33.0%) among 11,676 patients. Within the elective non-cardiac surgery category, elective orthopedic surgery was analyzed. In this subcategory, the pooled prevalence of unrecognized cognitive impairment was 37.0% (95% CI: 26.0%, 49.0%) among 1117 patients, and diagnosed cognitive impairment was 17.0% (95% CI: 3.0%, 60.0%) among 6871 patients. In cardiac surgeries, the unrecognized cognitive impairment prevalence across 588 patients was 26.0% (95% CI: 15.0%, 42.0%). In emergency surgeries, the unrecognized cognitive impairment prevalence was 50.0% (95% CI: 35.0%, 65.0%) among 2389 patients. CONCLUSIONS A substantial number of surgical patients had unrecognized cognitive impairment. In elective non-cardiac and emergency surgeries, the pooled prevalence of unrecognized cognitive impairment was 37.0% and 50.0%. Preoperative cognitive screening warrants more attention for risk assessment and stratification.
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Bhushan S, Li Y, Huang X, Cheng H, Gao K, Xiao Z. Progress of research in postoperative cognitive dysfunction in cardiac surgery patients: A review article. Int J Surg 2021; 95:106163. [PMID: 34743049 DOI: 10.1016/j.ijsu.2021.106163] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 10/19/2021] [Accepted: 11/02/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) is a common complication of central nervous system in middle-aged and elderly patients after cardiac surgery. The purpose of this study was to review the progress in diagnosis, pathogenesis and risk factors and control strategy of POCD. METHODS A systematic literature search was conducted using Pubmed and EMBASE, using the Mesh terms and key words "POCD", "diagnostic criteria", "pathogenesis", "influencing factors" and "prevention strategies". Studies were retained for review after meeting strict inclusion criteria that included only prospective studies evaluating risk factors for POCD in patients who had elective cardiac surgery. Diagnosis of POCD needed to be confirmed using the Diagnostic and Statistical Manual of Montreal Cognitive Assessment (MoCA) Scale and other criteria. RESULTS "Twenty two articles were selected for inclusion. The incidence of POCD across the studies ranged from 9% to 54%. Multiple factors have been associated with the pathogenesis and increased risk of POCD, including neuroinflammation, dysfunction of cholinergic system, abnormal protein function (β-amyloid), old age, anesthetic, surgical and other factors." CONCLUSIONS POCD is a common complication after cardiac surgery in elderly. The highest POCD incidence was observed after open aortic, TAVI and CABG surgery. Age, cognitive function, depression, CPB and anesthetic use are leading risk factors. Further research is needed in determining interventions that will be effective in preventing and treating POCD in cardiac surgical setting.
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Affiliation(s)
- Sandeep Bhushan
- Department of Cardiothoracic Surgery, Chengdu Second People's Hospital, Chengdu, Sichuan, 610017, China Department of Anesthesiology, West China Hospital of Medicine, Sichuan University, Sichuan, 610017, China
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Bhushan S, Li Y, Huang X, Cheng H, Gao K, Xiao Z. Progress of research in postoperative cognitive dysfunction in cardiac surgery patients: A review article. Int J Surg 2021. [DOI: https://doi.org/10.1016/j.ijsu.2021.106163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Thillainadesan J, Aitken SJ, Monaro SR, Cullen JS, Kerdic R, Hilmer SN, Naganathan V. Geriatric Comanagement of Older Vascular Surgery Inpatients Reduces Hospital-Acquired Geriatric Syndromes. J Am Med Dir Assoc 2021; 23:589-595.e6. [PMID: 34756839 DOI: 10.1016/j.jamda.2021.09.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE This study evaluates the impact of a novel model of care called Geriatric Comanagement of Older Vascular surgery inpatients on clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS A pre-post study of geriatric comanagement, comparing prospectively recruited preintervention (February-October 2019) and prospectively recruited postintervention (January-December 2020) cohorts. Consecutively admitted vascular surgery patients age ≥65 years at a tertiary academic hospital in Concord and with an expected length of stay (LOS) greater than 2 days were recruited. INTERVENTION A comanagement model where a geriatrician was embedded within the vascular surgery team and delivered proactive comprehensive geriatric assessment based interventions. METHODS Primary outcomes of incidence of hospital-acquired geriatric syndromes, delirium, and LOS were compared between groups using univariable and multivariable logistic regression analyses. Prespecified subgroup analysis was performed by frailty status. RESULTS There were 150 patients in the preintervention group and 152 patients in the postintervention group. The postintervention group were more frail [66 (43.4%) vs 45 (30.0%)], urgently admitted [72 (47.4%) vs 56 (37.3%)], and nonoperatively managed [52 (34.2%) vs 33 (22.0%)]. These differences were attributed to the coronavirus disease 2019 pandemic during the postintervention phase. The postintervention group had fewer hospital-acquired geriatric syndromes [74 (48.7%) vs 97 (64.7%); P = .005] and reduced incident delirium [5 (3.3%) vs 15 (10.0%); P = .02], in unadjusted and adjusted analyses. Cardiac [8 (5.3%) vs 30 (20.0%); P < .001] and infective complications [4 (2.6%) vs 12 (8.0%); P = .04] were also fewer. LOS was unchanged. Frail patients in the postintervention group experienced significantly fewer geriatric syndromes including delirium. CONCLUSIONS AND IMPLICATIONS This is the first prospective study of inpatient geriatric comanagement for older vascular surgery patients. Reductions in hospital-acquired geriatric syndromes including delirium, and cardiac and infective complications were observed after implementing geriatric comanagement. These benefits were also demonstrated in the frail subgroup.
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Affiliation(s)
- Janani Thillainadesan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia.
| | - Sarah J Aitken
- Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Concord Institute of Academic Surgery, Vascular Surgery Department, Concord Hospital, Concord, Sydney, Australia; Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sue R Monaro
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia; Susan Wakil School of Nursing, The University of Sydney, Sydney, Australia
| | - John S Cullen
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
| | - Richard Kerdic
- Department of Vascular Surgery, Concord Hospital, Concord, Sydney, Australia
| | - Sarah N Hilmer
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney and Royal North Shore Hospital, St Leonards, Sydney, Australia
| | - Vasi Naganathan
- Department of Geriatric Medicine, Concord Hospital, Concord, Sydney, Australia; Concord Clinical School, Faculty of Medicine and Health, The University of Sydney, Concord, Sydney, Australia; Center for Education and Research on Aging, and Aging and Alzheimers Institute, Concord, Sydney, Australia
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16
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Shan L. Mind Matters. Eur J Vasc Endovasc Surg 2021; 61:675. [PMID: 33541752 DOI: 10.1016/j.ejvs.2020.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 12/04/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Leonard Shan
- Department of Vascular Surgery, St. Vincent's Hospital, Melbourne, Australia.
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