Incidence and risk factors for impaired mobility in older cardiac surgery patients during the early postoperative period

Predictive factors of functional limitation after cardiac surgery: a retrospective cohort study

BACKGROUND

Functional limitation is relatively common and can negatively influence the postoperative outcome of patients after cardiac surgery.

OBJECTIVE

To identify the predictive factors of functional limitation in patients undergoing elective cardiac surgery.

METHODS

Retrospective cohort study was performed to evaluate patients undergoing elective cardiac surgery. All patients underwent a cardiovascular rehabilitation protocol. Functional limitation was defined based on performance in the rehabilitation protocol following cardiac surgery. Poor performance in the cardiac surgery rehabilitation protocol defined functional limitation, whereas good performance indicated no limitation.

RESULTS

Data were collected from 548 patients; of these, 190 (34.7%) had functional limitation. In multivariate analysis, the factors associated with postoperative functional limitation were as follows: hospitalization by the public healthcare system [OR: 2.14; 95% confidence interval (CI): 1.73, 2.65]; age (OR 1.23; 95% CI: 1.15, 1.31); length of hospitalization in the intensive care unit (OR 1.03; 95% CI: 1.01, 1.05); history of previous acute myocardial infarction (OR 1.40; 95% CI: 1.13, 1.73); presence of previous comorbidities [chronic kidney disease (OR 1.56; 95% CI: 1.15, 2.10); cerebrovascular disease (OR 1.57; 95% CI: 1.19, 2.07)]; presence of expiratory muscle weakness (OR 1.54; 95% CI: 1.08, 2.20); and intercurrence of cardiorespiratory arrest during hospitalization (OR 1.76; 95% CI: 1.40, 2.22).

CONCLUSION

Functional limitation after cardiac surgery could be predicted by multiple pre and postoperative factors, except for preoperative functionality, which does not suggest to be an independent factor for functional limitation after surgery.

Cognitive function in older patients and their stress challenge using different anesthesia regimes: a single center observational study

BACKGROUND

With increasing age older patients are at higher risk for cognitive decline after surgery. Even tailored anesthesia procedures in older patients remain a high risk for postoperative cognitive disorder. Additional stress derived from anxiety and anesthesia itself can negatively impact postoperative cognitive outcomes. The objective of this study was to evaluate the impact of general versus regional anesthesia on postoperative cognitive disorder and indicators of perioperative stress in elderly undergoing surgery.

METHODS

In this single center prospective study between December 2014 and November 2015, 46 patients aged 50 to 85 years undergoing dermatology surgery were enrolled. Patients were stratified by receiving general versus regional nerve anesthesia. On three consecutive days, saliva cortisol levels were analyzed three times per day. Cognitive function was assessed on the day before and the day after surgery using comprehensive neuropsychological testing of multiple cognitive functions including memory, executive function, attention and processing speed.

RESULTS

Comparing the regional anesthesia group (RAG, n = 28) with the general anesthesia group (GAG, n = 18) no significant difference in the postoperative cognitive function was observed. However, patients in the GAG had significantly higher postoperative cortisol levels when compared to patients in the RAG. In both groups, a peak of cortisol value was detected on the day of surgery, which was higher in the GAG in comparison to the RAG.

CONCLUSIONS

We did not observe a difference in postoperative cognitive function between patients undergoing regional or general anesthesia for dermatology surgery. However, we found lower cortisol level in the RAG. Based on these findings, future studies should investigate alternatives to reduce stress in a general anesthesia setting.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT02505815.

Improvement in Physical Function After Coronary Artery Bypass Graft Surgery Using a Novel Rehabilitation Intervention: A RANDOMIZED CONTROLLED TRIAL

PURPOSE

Cardiorespiratory and skeletal muscle deconditioning occurs following coronary artery bypass graft surgery and hospitalization. Outpatient, phase 2 cardiac rehabilitation (CR) is designed to remediate this deconditioning but typically does not begin until several weeks following hospital discharge. Although an exercise program between discharge and the start of CR could improve functional recovery, implementation of exercise at this time is complicated by postoperative physical limitations and restrictions. Our objective was to assess the utility of neuromuscular electrical stimulation (NMES) as an adjunct to current rehabilitative care following postsurgical discharge and prior to entry into CR on indices of physical function in patients undergoing coronary artery bypass graft surgery.

METHODS

Patients were randomized to 4 wk of bilateral, NMES (5 d/wk) to their quadriceps muscles or no intervention (control). Physical function testing was performed at hospital discharge and 4 wk post-discharge using the Short Physical Performance Battery and the 6-min walk tests. Data from 37 patients (19 control/18 NMES) who completed the trial were analyzed. The trial was registered at ClinicalTrials.gov (NCT03892460).

RESULTS

Physical function measures improved from discharge to 4 wk post-surgery across our entire cohort (P < .001). Patients randomized to NMES, however, showed greater improvements in 6-min walk test distance and power output compared with controls (P < .01).

CONCLUSION

Our results provide evidence supporting the utility of NMES to accelerate recovery of physical function after coronary artery bypass graft surgery.

Effects of Supervised Early Resistance Training versus standard care on cognitive recovery following cardiac surgery via median sternotomy (the SEcReT study): protocol for a randomised controlled pilot study

Introduction

Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined.

Methods

This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer’s Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months.

Discussion

The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p. Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

Exercise Parameters and Outcome Measures Used in Cardiac Rehabilitation Programs Following Median Sternotomy in the Elderly: A Systematic Review and Meta-Analysis

OBJECTIVE

The aim of this systematic review was to identify exercise parameters and outcome measures used in cardiac rehabilitation programs following median sternotomy, in the elderly cardiac population.

DATA SOURCES

Five (5) electronic databases were searched for relevant studies published in English after 1997.

STUDY SELECTION

The screening process was completed by two independent researchers, with a third independent reviewer for overall agreement. Studies were selected if they included only cardiac patients aged ≥65 years who had undergone valve surgery and/or coronary artery bypass grafting via median sternotomy, and who had undertaken a postoperative cardiac rehabilitation exercise intervention assessing physical function and/or cognitive recovery as outcomes.

DATA EXTRACTION

Two researchers independently completed the data extraction and quality assessment. Quality was assessed using a modified Downs and Black tool.

DATA SYNTHESIS

In total, 11 articles were included for appraisal with respect to the quality of the study. Only two randomised controlled trials were suitable for meta-analysis. A higher volume of exercise was shown to have a positive effect on functional recovery, assessed using the 6-minute walk test (6MWT) (mean difference=26.97m; 95% confidence interval [CI], 6.96-46.97; p=0.008; I²=0%). No significant improvement was shown between additional exercise compared to standard care in improving VO_2peak, maximal power output or quality of life. No studies evaluated the effect of exercise on cognitive recovery.

CONCLUSIONS

Exercise significantly improves functional recovery in the post-surgical elderly cardiac population, however uncertainty still exists with regard to which modes of exercise and their specific parameters are most effective in improving cognitive recovery.

Effects of an abnormal mini-mental state examination score on postoperative outcomes in geriatric surgical patients: a meta-analysis

Background

Perioperative cognitive impairment (CI) following surgeries is prevalent in geriatric surgical population aged 60 and older. This meta-analysis was designed to investigate whether the Mini-Mental State Examination (MMSE) has prognostic value on adverse outcomes in aged surgical patients.

Methods

PubMed, Cochrane, Embase and Medline through the Ovid were searched. Meta-analyses were carried out for CI versus non-cognitive impairment (NCI). Quality of evidence was assessed by the GRADE approach.

Results

One randomized controlled trial, two retrospective cohort trials, and 18 prospective cohort trials were included in the meta-analysis. Perioperative diagnosis of CI by the MMSE had higher rates of patients suffering from postoperative delirium (POD) [odd ratio (OR) 5.02, 95% confidence interval (CI) 3.27, 7.71, P < 0.00001], in-hospital mortality (OR 7.51, 95% CI 2.17, 26.02, P = 0.001), mortality within 1 year (OR 2.53, 95% CI 1.95,3.29, P < 0.00001). Postoperative CI patients had no extended length of stay in orthopedic [standardized mean difference (SMD) -0.10, 95% CI -0.20, 0.17, P = 0.91)] nor rehabilitation wards ((SMD, 0.04; 95% CI, − 0.23 to 0.31; P = 0.78).

Conclusion

Older patients with perioperative CI were more likely to suffer from POD and mortality. The MMSE showed certain value on risk stratification and prognosis evaluation in geriatric surgical population.

Trial registration

PROSPERO CRD42018108739.

Electronic supplementary material

The online version of this article (10.1186/s12871-019-0735-5) contains supplementary material, which is available to authorized users.

In-Hospital Mobility Variations Across Primary Diagnoses Among Older Adults

OBJECTIVES

To examine the relationship between primary diagnoses and mobility impairment and recovery among hospitalized older adults.

DESIGN

Prospective cohort study.

SETTING

UF Health Shands Hospital, an 852-bed level I trauma center located in Gainesville, Florida.

PARTICIPANTS

A total of 18,551 older adults (≥65 years) with 29,148 hospitalizations between January 2009 and April 2014.

MEASUREMENTS

Incident and discharge mobility impairment and recovery were assessed using the Braden activity subscale score that was recorded by the nursing staff at every shift change: approximately 3 times per day. Primary diagnosis ICD-9 codes were used as predictors and recategorized by using the Agency for Health Care Research and Quality Clinical Classification Software.

RESULTS

Of the 15,498 hospital records in which the patient was initially observed to "walk frequently," 3186 (20.6%) developed incident mobility impairment (chair-fast or bedfast). Primary diagnoses with a surgical or invasive procedure were the most prevalent (77.2%) among the hospital observations with incident mobility impairment; otherwise, primary diagnoses without surgery were much more associated with discharge mobility impairment (59%). The highest incidence of mobility impairment occurred in patients with heart valve disorders and aortic and peripheral/visceral artery aneurysms (6.24 and 6.05 events per 30 person-days, respectively); septicemia showed the highest incidence rate for mobility limitation at discharge (0.94 events per 30 person-days). Mobility impairment was observed in 13,650 (46.8% of total) records at admission and 5930 (43.44%) were observed to recover to a state of walking occasionally or frequently. Osteoarthritis and cancer of gastrointestinal organs/peritoneum had the highest incidence rate for mobility recovery (7.68 and 5.63 events per 30 person-days respectively).

CONCLUSIONS

Approximately 1 of 5 patients who were mobile at admission became significantly impaired during hospitalization. However, approximately half (43.4%) of patients observed to have mobility impairment at admission recovered during hospitalization. Conditions most associated with mobility impairment and recovery are varied, but older patients hospitalized for septicemia and cardiovascular diseases with surgery (heart valve disorders and aortic/peripheral/visceral artery aneurysms) appear to be at most risk for incident mobility impairment that did not recover at discharge.