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Shang Z, Jiang Y, Fang P, Zhu W, Guo J, Li L, Liang Y, Zhang S, Ma S, Mei B, Fan Y, Xie Z, Shen Q, Liu X. The Association of Preoperative Diabetes With Postoperative Delirium in Older Patients Undergoing Major Orthopedic Surgery: A Prospective Matched Cohort Study. Anesth Analg 2024; 138:1031-1042. [PMID: 38335150 DOI: 10.1213/ane.0000000000006893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024]
Abstract
BACKGROUND Postoperative delirium (POD) is a common form of postoperative brain dysfunction, especially in the elderly. However, its risk factors remain largely to be determined. This study aimed to investigate whether (1) preoperative diabetes is associated with POD after elective orthopedic surgery and (2) intraoperative frontal alpha power is a mediator of the association between preoperative diabetes and POD. METHODS This was a prospective matched cohort study of patients aged 60 years or more, with a preoperative diabetes who underwent elective orthopedic surgery. Nondiabetic patients were matched 1:1 to diabetic patients in terms of age, sex, and type of surgery. Primary outcome was occurrence of POD, assessed using the 3-minute Diagnostic Confusion Assessment Method (3D-CAM) once daily from 6 pm to 8 pm during the postoperative days 1-7 or until discharge. Secondary outcome was the severity of POD which was assessed for all participants using the short form of the CAM-Severity. Frontal electroencephalogram (EEG) was recorded starting before induction of anesthesia and lasting until discharge from the operating room. Intraoperative alpha power was calculated using multitaper spectral analyses. Mediation analysis was used to estimate the proportion of the association between preoperative diabetes and POD that could be explained by intraoperative alpha power. RESULTS A total of 138 pairs of eligible patients successfully matched 1:1. After enrollment, 6 patients in the diabetes group and 4 patients in the nondiabetes group were excluded due to unavailability of raw EEG data. The final analysis included 132 participants with preoperative diabetes and 134 participants without preoperative diabetes, with a median age of 68 years and 72.6% of patients were female. The incidence of POD was 16.7% (22/132) in patients with preoperative diabetes vs 6.0% (8/134) in patients without preoperative diabetes. Preoperative diabetes was associated with increased odds of POD after adjustment of age, sex, body mass index, education level, hypertension, arrhythmia, coronary heart disease, and history of stroke (odds ratio, 3.2; 95% confidence interval [CI], 1.4-8.0; P = .009). The intraoperative alpha power accounted for an estimated 20% (95% CI, 2.6-60%; P = .021) of the association between diabetes and POD. CONCLUSIONS This study suggests that preoperative diabetes is associated with an increased risk of POD in older patients undergoing major orthopedic surgery, and that low intraoperative alpha power partially mediates such association.
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Affiliation(s)
- Zixiang Shang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yu Jiang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Panpan Fang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Wenjie Zhu
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Jiaxin Guo
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Lili Li
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yongjie Liang
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Sichen Zhang
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, P.R. China
| | - Shenglan Ma
- Department of Psychiatry, Affiliated Psychological Hospital of Anhui Medical University, Hefei, P.R. China
| | - Bin Mei
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Yinguang Fan
- Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, P.R. China
| | - Zhongcong Xie
- Geriatric Anesthesia Research Unit, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Charlestown, Massachusetts
| | - Qiying Shen
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
| | - Xuesheng Liu
- From the Department of Anesthesiology, The First Affiliated Hospital of Anhui Medical University, Hefei, P.R. China
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Wong CWY, Li PWC, Yu DSF, Ho BMH, Chan BS. Estimated prevalence of frailty and prefrailty in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and proportional meta-analysis. Ageing Res Rev 2024; 96:102266. [PMID: 38462047 DOI: 10.1016/j.arr.2024.102266] [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: 11/06/2023] [Revised: 02/23/2024] [Accepted: 03/06/2024] [Indexed: 03/12/2024]
Abstract
BACKGROUND The aging population has led to an increasing number of older patients undergoing cardiac surgeries/procedures. Frailty and prefrailty have emerged as important prognostic indicators among these patients. This proportional meta-analysis estimated the prevalence of frailty and prefrailty among patients undergoing cardiac surgery. METHODS We searched seven electronic databases for observational studies that used validated measure(s) of frailty and reported prevalence data on frailty and/or prefrailty in older patients undergoing coronary artery or valvular surgeries or transcatheter procedures. Meta-analyses were performed using a random-effects model. RESULTS One hundred and one articles involving 626,863 patients were included. The pooled prevalence rates of frailty and prefrailty were 28% (95% confidence interval [CI]: 23%-33%) and 40% (95% CI: 31%-50%), respectively, for patients scheduled for open-heart surgeries and 40% (95% CI: 36%-45%) and 43% (95% CI: 34%-53%), respectively, for patients undergoing transcatheter procedures. Frailty measured using a multidimensional approach identified a higher proportion of frail patients when compared with measures solely focused on physical frailty. Older age, female sex, and lower body mass index and hemoglobin concentrations were significantly associated with higher frailty prevalence. Moreover, countries with higher gross domestic product spent on healthcare exhibited a higher frailty prevalence. CONCLUSION Frailty represents a considerable health challenge among patients undergoing cardiac surgeries/procedures. Routine screening for frailty should be considered during perioperative care planning.
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Affiliation(s)
- Cathy W Y Wong
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong , Hong Kong
| | - Polly W C Li
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong , Hong Kong.
| | - Doris S F Yu
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong , Hong Kong
| | - Benjamin M H Ho
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong , Hong Kong
| | - Bernice Shinyi Chan
- School of Nursing, Li Ka Shing Faculty of Medicine, The University of Hong Kong , Hong Kong
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Bakhtiari M, Shaker F, Shirmard FO, Jalali A, Vakili-Basir A, Balabandian M, Khamene SS, Mohammadkhawajah I, Shafiee A, Badrkhahan SZ, Hosseini K. Frailty efficacy as a predictor of clinical and cognitive complications in patients undergoing coronary artery bypass grafting: a prospective cohort study. BMC Cardiovasc Disord 2024; 24:110. [PMID: 38365571 PMCID: PMC10874082 DOI: 10.1186/s12872-024-03781-7] [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: 12/10/2023] [Accepted: 02/11/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Frailty is proposed as a predictor of outcomes in patients undergoing major surgeries, although data on the association of frailty and coronary artery bypass grafting (CABG) are lacking. We assessed the association between frailty and cognitive and clinical complications following CABG. METHODS This prospective study included patients aged over 60 years undergoing elective CABG at Tehran Heart Center from 2020 to 2022. Baseline and three-month follow-up data on frailty using the Frail scale and clinical Frail scale, functional status using the Lawton Instrumental Activities of Daily Living Scale (IADL), cognitive function by Montreal Cognitive Assessment (MoCA), and depression by the Geriatric Depression Scale (GDS) were obtained. The incidence of adverse outcomes was investigated at the three-month follow-up. Outcomes between frail and non-frail groups were compared utilizing T-tests and Mann-Whitney U tests, as appropriate. RESULTS We included 170 patients with a median age of 66 ± 4 years (75.3% male). Of these, 58 cases were classified as frail, and 112 individuals were non-frail, preoperatively. Frail patients demonstrated significantly worse baseline MOCA scores (21.08 vs. 22.41, P = 0.045), GDS (2.00 vs. 1.00, P = 0.009), and Lawton IADL (8.00 vs. 6.00, P < 0.001) compared to non-frail. According to 3-month follow-up data, postoperative MOCA and GDS scores were comparable between the two groups, while Lawton IADL (8.00 vs. 6.00, P < 0.001) was significantly lower in frail cases. A significantly higher rate of readmission (1.8% vs. 12.1%), sepsis (7.1% vs. 19.0%), as well as a higher Euroscore (1.5 vs. 1.9), was observed in the frail group. A mildly significantly more extended ICU stay (6.00 vs. 5.00, p = 0.051) was shown in the frail patient. CONCLUSION Frailty showed a significant association with a worse preoperative independence level, cognitive function, and depression status, as well as increased postoperative complications.
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Affiliation(s)
- Mehrnoosh Bakhtiari
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Farhad Shaker
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Fatemeh Ojaghi Shirmard
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Arash Jalali
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Ahmad Vakili-Basir
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Sima Shamshiri Khamene
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Izat Mohammadkhawajah
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Akbar Shafiee
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran
| | - Seyedeh Zahra Badrkhahan
- Cardiac Primary Prevention Research Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, Tehran, Iran
- Department of Geriatric Medicine, Tehran University of Medical Sciences (TUMS), Tehran, Iran
| | - Kaveh Hosseini
- Tehran Heart Center, Cardiovascular Diseases Research Institute, Tehran University of Medical Sciences, North Kargar Ave, Tehran, Iran.
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Browndyke JN, Tomalin LE, Erus G, Overbey JR, Kuceyeski A, Moskowitz AJ, Bagiella E, Iribarne A, Acker M, Mack M, Mathew J, O'Gara P, Gelijns AC, Suarez‐Farinas M, Messé SR. Infarct-related structural disconnection and delirium in surgical aortic valve replacement patients. Ann Clin Transl Neurol 2024; 11:263-277. [PMID: 38155462 PMCID: PMC10863920 DOI: 10.1002/acn3.51949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 10/28/2023] [Indexed: 12/30/2023] Open
Abstract
OBJECTIVE Although acute brain infarcts are common after surgical aortic valve replacement (SAVR), they are often unassociated with clinical stroke symptoms. The relationship between clinically "silent" infarcts and in-hospital delirium remains uncertain; obscured, in part, by how infarcts have been traditionally summarized as global metrics, independent of location or structural consequence. We sought to determine if infarct location and related structural connectivity changes were associated with postoperative delirium after SAVR. METHODS A secondary analysis of a randomized multicenter SAVR trial of embolic protection devices (NCT02389894) was conducted, excluding participants with clinical stroke or incomplete neuroimaging (N = 298; 39% female, 7% non-White, 74 ± 7 years). Delirium during in-hospital recovery was serially screened using the Confusion Assessment Method. Parcellation and tractography atlas-based neuroimaging methods were used to determine infarct locations and cortical connectivity effects. Mixed-effect, zero-inflated gaussian modeling analyses, accounting for brain region-specific infarct characteristics, were conducted to examine for differences within and between groups by delirium status and perioperative neuroprotection device strategy. RESULTS 23.5% participants experienced postoperative delirium. Delirium was associated with significantly increased lesion volumes in the right cerebellum and temporal lobe white matter, while diffusion weighted imaging infarct-related structural disconnection (DWI-ISD) was observed in frontal and temporal lobe regions (p-FDR < 0.05). Fewer brain regions demonstrated DWI-ISD loss in the suction-based neuroprotection device group, relative to filtration-based device or standard aortic cannula. INTERPRETATION Structural disconnection from acute infarcts was greater in patients who experienced postoperative delirium, suggesting that the impact from covert perioperative infarcts may not be as clinically "silent" as commonly assumed.
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Affiliation(s)
- Jeffrey N. Browndyke
- Division of Behavioral Medicine and Neurosciences, Department of Psychiatry and Behavioral SciencesDuke University Medical CenterDurhamNorth CarolinaUSA
- Division of Cardiovascular and Thoracic Surgery, Department of SurgeryDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Lewis E. Tomalin
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Guray Erus
- Department of RadiologyUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Jessica R. Overbey
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Amy Kuceyeski
- Department of RadiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
- Brain and Mind Research InstituteWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Alan J. Moskowitz
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Emilia Bagiella
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Alexander Iribarne
- Department of Cardiothoracic SurgeryStaten Island University Hospital, Northwell Health Staten IslandNew YorkNew YorkUSA
| | - Michael Acker
- Division of Cardiovascular Surgery, Department of SurgeryUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
| | - Michael Mack
- Department of Cardiothoracic SurgeryBaylor Research Institute, Baylor Scott and White HealthPlanoTexasUSA
| | - Joseph Mathew
- Department of AnesthesiologyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Patrick O'Gara
- Cardiovascular Division, Department of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Annetine C. Gelijns
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Mayte Suarez‐Farinas
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Steven R. Messé
- Department of NeurologyUniversity of Pennsylvania School of MedicinePhiladelphiaPennsylvaniaUSA
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Feng C, Wu H, Qi Z, Wei Y, Yang B, Yin H, Yan S, Wang L, Yu Y, Xie J, Xing X, Tu S, Zhang H. Association of preoperative frailty with the risk of postoperative delirium in older patients undergoing hip fracture surgery: a prospective cohort study. Aging Clin Exp Res 2024; 36:16. [PMID: 38294584 PMCID: PMC10830592 DOI: 10.1007/s40520-023-02692-5] [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: 09/22/2023] [Accepted: 12/31/2023] [Indexed: 02/01/2024]
Abstract
OBJECTIVE This study aimed to explore the correlation between preoperative frailty and the risk of postoperative delirium (POD) in older patients undergoing hip fracture surgery. METHODS In total, 148 patients with hip fractures who were admitted to Tsinghua Changgung Hospital (Beijing, China) between January 2022 and January 2023 were involved in this study. Preoperative frailty scales were assessed, of which the CAM scale was postoperatively administered every morning and evening on days 1, 2, 3, 5, and 7. Binary logistic regression analysis was conducted to determine the correlation between preoperative frailty and the risk of POD. RESULTS Among 148 older patients with hip fractures, 71 (48.0%) were identified as preoperative frail and 77 (52.0%) as non-frail. The overall incidence of POD on day 7 was 24.3% (36/148), and preoperative frailty was associated with a significantly higher risk of POD compared with non-frailty (42.3% vs. 7.8%, P < 0.001). The binary logistic regression analysis revealed that preoperative frailty was noted as an independent risk factor for the risk of POD in older patients undergoing hip fracture surgery (P = 0.002). CONCLUSION Preoperative frailty increased the risk of POD in older patients undergoing hip fracture surgery. DISCUSSION Preoperative assessment of frailty in geriatric hip surgery can timely identify potential risks and provide interventions targeting frailty factors to reduce the incidence of POD in older patients undergoing hip fracture surgery. The findings suggested that preoperative frailty could increase the risk of POD in older patients undergoing hip fracture surgery. Further research is necessary to determine whether perioperative interventions aimed at enhancing frailty can mitigate the risk of POD and improve prognosis in older patients undergoing hip fracture surgery.
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Affiliation(s)
- Chunyu Feng
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Haotian Wu
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Ziheng Qi
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Yuzhi Wei
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Bo Yang
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Haolin Yin
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Siyi Yan
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Lu Wang
- School of Clinical Medicine, Tsinghua University, Beijing, China
- Department of Plastic Surgery, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Yangyang Yu
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Juanjuan Xie
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Xueyan Xing
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Shumin Tu
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China
| | - Huan Zhang
- School of Clinical Medicine, Tsinghua University, Beijing, China.
- Department of Anesthesiology, Beijing Tsinghua Changgung Hospital, No.168 Litang Road, Changping District, Beijing, 102218, China.
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Niebauer J, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Sündermann SH. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Prev Cardiol 2024; 31:146-181. [PMID: 37804173 DOI: 10.1093/eurjpc/zwad304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
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Mi X, Jia Y, Song Y, Liu K, Liu T, Han D, Yang N, Wang G, Guo X, Yuan Y, Li Z. Preoperative prognostic nutritional index value as a predictive factor for postoperative delirium in older adult patients with hip fractures: a secondary analysis. BMC Geriatr 2024; 24:21. [PMID: 38178002 PMCID: PMC10768121 DOI: 10.1186/s12877-023-04629-z] [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: 06/29/2023] [Accepted: 12/20/2023] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND Malnutrition is a common geriatric syndrome and can be targeted preoperatively to decrease the risk of postoperative delirium (POD) in older adult patients. To analyze the value of the prognostic nutritional index (PNI) to predict the incidence of POD in older adult patients with hip fractures. METHODS This was a prospective, observational, cohort study of older adult patients with hip fractures. Preoperative PNI was calculated as 10 × serum albumin (g/dL) + 0.005 × total lymphocyte count (/μL) using preoperative laboratory results. Patients were divided into POD and non-POD groups using the Confusion Assessment Method (CAM). The risk factors associated with POD as well as the relationship between PNI values and the incidence of POD were analyzed using univariate and multivariate logistic regression analyses. The predictive value of PNI for POD was assessed using receiver operating characteristic curve analysis. RESULTS In this cohort of 369 patients who underwent hip fracture surgery, 67 patients (18.2%) were diagnosed with POD by the CAM results. Low PNI increased the risk of POD (odds ratio (OR) = 0.928, 95% confidence interval (CI): 0.864-0.997). General anesthesia (OR = 2.307, 95% CI: 1.279-4.162) and Mini-Mental State Examination (MMSE) score (OR = 0.956, 95% CI: 0.920-0.994) were also identified as risk factors for POD. Receiver operating characteristic curve analysis suggested that PNI combined with the anesthetic method and MMSE score may be used as a potential predictive indicator of POD after hip fracture surgery. CONCLUSION Preoperative PNI value is related to POD in older adult patients with hip fractures. TRIAL REGISTRATION This secondary analysis study was approved by the Peking University Third Hospital Medical Science Research Ethics Committee (approval No. M2022578) and registered in the Chinese Clinical Trial Registry (ChiCTR2300070569).
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Affiliation(s)
- Xinning Mi
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Yunyang Jia
- Department of Orthopaedics & Traumatology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Yanan Song
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Kaixi Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Taotao Liu
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Dengyang Han
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Ning Yang
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
| | - Geng Wang
- Department of Anesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China
| | - Xiangyang Guo
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China
- Beijing Center of Quality Control and Improvement On Clinical Anesthesia, Beijing, 100191, China
- Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, China
| | - Yi Yuan
- Department of Anesthesiology, Beijing Jishuitan Hospital, Capital Medical University, Beijing, 100035, China.
| | - Zhengqian Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, 100191, China.
- Beijing Center of Quality Control and Improvement On Clinical Anesthesia, Beijing, 100191, China.
- Perioperative Medicine Branch of China International Exchange and Promotive Association for Medical and Health Care (CPAM), Beijing, 100191, China.
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Arefayne NR, Berhe YW, van Zundert AA. Incidence and Factors Related to Prolonged Postoperative Cognitive Decline (POCD) in Elderly Patients Following Surgery and Anaesthesia: A Systematic Review. J Multidiscip Healthc 2023; 16:3405-3413. [PMID: 37964799 PMCID: PMC10642348 DOI: 10.2147/jmdh.s431168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Aim The aim of this systematic review is to explore the current literature to provide evidence regarding the incidence and risk factors of prolonged POCD in elderly patients following cardiac and non-cardiac surgical interventions. Methods The PubMed and Google Scholar databases were searched using appropriate keywords and search engines for adequate evidence from studies meeting the inclusion criteria so as to reveal the end-point, which was the presence of prolonged POCD in elderly patients following surgery and anaesthesia. The incidence of POCD at different time intervals and the variables predicting the occurrence of POCD were analysed. Results The results of 23 articles covering 5077 patients (3694 non cardiac and 1383 cardiac surgeries) were carefully analysed. POCD occurs from the first postoperative day and lasts for potentially long periods. The incidence of POCD in this review ranged from 2.2% to 35.7%. More specifically, it ranged from 2.2% to 31.5% in non-cardiac surgeries and 11.8% to 35.7% in patients who had undergone cardiac surgeries. Some of the independent risk factors (predictors) for the development of POCD were advanced age, high concentration of neuroinflammatory mediators detectable in plasma, low SpO2, longer anaesthetic and surgical duration, and depth of anaesthesia. Conclusion This review can only provide limited evidence of prolonged POCD (more than a year) and further research that involves better study designs, larger samples, involving longer follow-up, and at different sites (multicentre) is highly advised. This in turn may help researchers and clinicians to discover the actual causes and risk factors and develop appropriate preventive and treatment protocols to tackle POCD in the ageing surgical population.
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Affiliation(s)
- Nurhusen Riskey Arefayne
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Yophtahe Woldegerima Berhe
- Department of Anaesthesia, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - André A van Zundert
- The University of Queensland & Royal Brisbane and Women’s Hospital, Department of Anaesthesia and Perioperative Medicine, Brisbane, QLD, Australia
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9
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Dammavalam V, Murphy J, Johnkutty M, Elias M, Corn R, Bergese S. Perioperative cognition in association with malnutrition and frailty: a narrative review. Front Neurosci 2023; 17:1275201. [PMID: 38027517 PMCID: PMC10651720 DOI: 10.3389/fnins.2023.1275201] [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: 08/09/2023] [Accepted: 10/18/2023] [Indexed: 12/01/2023] Open
Abstract
Postoperative delirium (POD) is a prevalent clinical entity characterized by reversible fluctuating altered mental status and cognitive impairment with acute and rapid onset a few days after major surgery. Postoperative cognitive decline (POCD) is a more permanent extension of POD characterized by prolonged global cognitive impairment for several months to years after surgery and anesthesia. Both syndromes have been shown to increase morbidity and mortality in postoperative patients making their multiple risk factors targets for optimization. In particular, nutrition imparts a significant and potentially reversible risk factor. Malnutrition and frailty have been linked as risk factors and predictive indicators for POD and less so for POCD. This review aims to outline the association between nutrition and perioperative cognitive outcomes as well as potential interventions such as prehabilitation.
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Affiliation(s)
- Vikalpa Dammavalam
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Jasper Murphy
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Meenu Johnkutty
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Murad Elias
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Ryan Corn
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | - Sergio Bergese
- Department of Anesthesiology, Stony Brook University Hospital, Stony Brook, NY, United States
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10
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Sündermann SH, Bäck C, Bischoff-Ferrari HA, Dehbi HM, Szekely A, Völler H, Niebauer J. Preinterventional frailty assessment in patients scheduled for cardiac surgery or transcatheter aortic valve implantation: a consensus statement of the European Association for Cardio-Thoracic Surgery (EACTS) and the European Association of Preventive Cardiology (EAPC) of the European Society of Cardiology (ESC). Eur J Cardiothorac Surg 2023; 64:ezad181. [PMID: 37804175 DOI: 10.1093/ejcts/ezad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 03/22/2023] [Indexed: 10/09/2023] Open
Affiliation(s)
- Simon H Sündermann
- Deutsches Herzzentrum der Charité, Department of Cardiothoracic and Vascular Surgery, Berlin, Germany
- Charité- Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- DZHK (German Center of Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Caroline Bäck
- Department of Cardiothoracic Surgery, RT, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Heike A Bischoff-Ferrari
- Center on Ageing and Mobility, University Hospital and University of Zurich, Zurich, Switzerland
| | - Hakim-Moulay Dehbi
- University College London, Comprehensive Clinical Trials Unit, London, Great Britain
| | - Andrea Szekely
- Semmelweis University, Department of Anesthesiology and Intensive Therapy, Budapest, Hungary
| | - Heinz Völler
- Faculty of Health Sciences Brandenburg, University of Potsdam, Department of Rehabilitation Medicine, Potsdam, Germany
- Klinik am See, Rehabilitation Centre for Internal Medicine, Rüdersdorf, Germany
| | - Josef Niebauer
- Paracelsus Medical University Salzburg, Institute of Sports Medicine, Prevention and Rehabilitation, Salzburg, Austria
- Ludwig Boltzmann Institute for Digital Health and Prevention, Salzburg, Austria
- REHA-Zentrum Salzburg, University Hospital Salzburg, Austria
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11
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Amirfarzan H, Azocar RJ, Shapeton AD. "The Big Three" of geriatrics: A review of perioperative cognitive impairment, frailty and malnutrition. Saudi J Anaesth 2023; 17:509-516. [PMID: 37779565 PMCID: PMC10540988 DOI: 10.4103/sja.sja_532_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 06/20/2023] [Accepted: 06/21/2023] [Indexed: 10/03/2023] Open
Abstract
Cognitive impairment, frailty, and malnutrition are three of the most impactful pathologies facing an aging population, having dramatic effects on morbidity and mortality across nearly all facets of medical care and intervention. By 2050, the World Health Organization estimates that the population of individuals over the age of sixty worldwide will nearly double, and the public health toll of these demographic changes cannot be understated. With these changing demographics comes a need for a sharpened focus on the care and management of this vulnerable population. The average patient presenting for surgery is getting older, and this necessitates that clinicians understand the implications of these pathologies for both their immediate medical care needs and for appropriate procedural selection and prognostication of surgical outcomes. We believe it is incumbent on clinicians to consider the frailty, nutritional status, and cognitive function of each individual patient when offering a surgical intervention, as well as consider interventions that may delay the progression of these pathologies. Unfortunately, despite excellent evidence supporting things like routine pre-operative frailty screening and nutritional optimization, many interventions that would specifically benefit this population still have not been integrated into routine practice. In this review, we will synthesize the existing literature on these topics to provide a pragmatic approach and understanding for anesthesiologists and intensivists faced with this complex population.
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Affiliation(s)
- Houman Amirfarzan
- Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Ruben J. Azocar
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Alexander D. Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine, Tufts University School of Medicine, Boston, MA, USA
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12
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Ma Z, Wang J, He T, Zhu S, Sheng C, Ge Y, Yuan L. Correlation between preoperative frailty and postoperative delirium in elderly patients undergoing hip arthroplasty. Medicine (Baltimore) 2023; 102:e34785. [PMID: 37653780 PMCID: PMC10470691 DOI: 10.1097/md.0000000000034785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) refers to acute brain dysfunction occurring within 7 days after operation or before discharge. Frailty refers to the state that the body's physiological reserve is insufficient, so that the compensative capacity to endogenous and exogenous stress stimuli decreases. The purpose of this study is to explore the association of preoperative frailty (PF) with POD in elderly patients undergoing hip arthroplasty. METHODS Totally 228 elderly patients (age ≥ 65 years) who received elective hip arthroplasty in the Ningbo No. 6 Hospital between December 2021 and June 2022 were enrolled. One day before surgery, the frailty phenotype scale was adopted for evaluation of patients' frailty. On the 1st-3rd day after operation, the confusion assessment method was adopted for evaluation of delirium, and the patients were grouped into a POD group and non-POD group. Logistic regression was conducted to analyze the correlation between PF and POD. RESULTS Among the patients, the incidence of PF was 30.70% (70/228), and the incidence of delirium within 3 days after operation was 25.88% (59/228). According to binary logistic regression analysis, PF, age, hypertension, diabetes mellitus, and preoperative sleep disorder were independent risk factors for POD in elderly patients undergoing hip arthroplasty (all P < .05). CONCLUSION PF is a crucial risk factor for POD in elderly patients undergoing hip arthroplasty.
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Affiliation(s)
- Zihan Ma
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Jianlin Wang
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Tianyi He
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Shaoxiong Zhu
- Health Science Center, Ningbo University, Ningbo, Zhejiang, China
| | - Chaoxu Sheng
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Yeying Ge
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
| | - Liyong Yuan
- Department of Anesthesiology, Ningbo No. 6 Hospital, Ningbo, Zhejiang, China
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Ramos MD, Vergara FH, Shackleford J, Briggs C, Gomez C, Mofazali M, Preston J. Risk for post-operative delirium related to comorbidities in older adult cardiac patients: An integrative review. J Clin Nurs 2023; 32:2128-2139. [PMID: 35642091 DOI: 10.1111/jocn.16389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 03/03/2022] [Accepted: 05/16/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Delirium is defined as a sudden onset of confusion due to disruption in normal brain functioning. Although it is highly prevalent in post-operative patients, most significantly the older adult population, limited information exists explaining why its onset occurs. PURPOSE This integrative review aimed to synthesise specific comorbidities that can contribute to the development of post-operative delirium in older adult cardiac surgical patients. METHODS PRISMA statement was used to report the identification, selection, appraisal and synthesis of articles and the PRISMA diagram reports the selection process. The Johns Hopkins Evidence-Based Practice Tools were used as guide in literature review, critical analysis, levelling of evidence and quality rating. PubMed, ProQuest, CINAHL plus, EMBASE, MEDLINE, Ovid Nursing Collection and Cochrane databases were searched from 2015 to 2020. RESULTS The initial search yielded 1529 articles. Following the removal of duplicates and screening, 14 articles were included for this review. The following comorbidities were identified in the studies: Diabetes mellitus, atrial fibrillation, depression, impaired olfaction, pre-existing cerebrovascular disease, pre-existing cardiovascular disease, insomnia and frailty. CONCLUSION There was a strong indication of the development of post-operative delirium among older adult cardiac surgical patients with comorbidities. RELEVANCE TO CLINICAL PRACTICE Awareness of the impact of comorbidities in developing post-operative delirium may help healthcare providers to plan and implement proper care management among older adult cardiac surgical patients with comorbidities.
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Affiliation(s)
- Mary Dioise Ramos
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
| | | | - Jenna Shackleford
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
| | - Christina Briggs
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
| | - Carolina Gomez
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
| | - Mahdi Mofazali
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
| | - Jade Preston
- WellStar School of Nursing, Kennesaw State University, Kennesaw, Georgia, USA
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14
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Tang AB, Diaz‐Ramirez LG, Smith AK, Lee SJ, Whitlock EL. Preoperative Factors Predict Memory Decline After Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention in an Epidemiological Cohort of Older Adults. J Am Heart Assoc 2023; 12:e027849. [PMID: 36583424 PMCID: PMC9973564 DOI: 10.1161/jaha.122.027849] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
Background Durable memory decline may occur in older adults after surgical (coronary artery bypass grafting [CABG]) or nonsurgical (percutaneous coronary intervention) coronary revascularization. However, it is unknown whether individual memory risk can be predicted. We reanalyzed an epidemiological cohort of older adults to predict memory decline at ≈1 year after revascularization. Methods and Results We studied Health and Retirement Study participants who underwent CABG or percutaneous coronary intervention at age ≥65 years between 1998 and 2015 and participated in ≥1 biennial postprocedure assessment. Using a memory score based on direct and proxy cognitive tests, we identified participants whose actual postprocedure memory score was 1-2 ("mild") or >2 ("major") SDs below expected postprocedure performance. We modeled probability of memory decline using logistic regression on preoperatively known factors and evaluated model discrimination and calibration. A total of 1390 participants (551 CABG, 839 percutaneous coronary intervention) underwent CABG/percutaneous coronary intervention at 75±6 years old; 40% were women. The cohort was 83% non-Hispanic White, 8.4% non-Hispanic Black, 6.4% Hispanic ethnicity, and 1.7% from other groups masked by the HRS (Health and Retirement Study) to preserve participant confidentiality. At a median of 1.1 (interquartile range, 0.6-1.6) years after procedure, 267 (19%) had mild memory decline and 88 (6.3%) had major memory decline. Factors predicting memory decline included older age, frailty, and off-pump CABG; obesity was protective. The optimism-corrected area under the receiver operator characteristic curve was 0.73 (95% CI, 0.71-0.77). A cutoff of 50% probability of memory decline identified 14% of the cohort as high risk, and was 94% specific and 30% sensitive for late memory decline. Conclusions Preoperative factors can be used to predict late memory decline after coronary revascularization in an epidemiological cohort with high specificity.
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Affiliation(s)
| | | | - Alexander K. Smith
- Division of Geriatrics, Department of MedicineUCSF School of MedicineSan FranciscoCA
| | - Sei J. Lee
- Division of Geriatrics, Department of MedicineUCSF School of MedicineSan FranciscoCA
| | - Elizabeth L. Whitlock
- Department of Anesthesia & Perioperative CareUCSF School of MedicineSan FranciscoCAUnited States
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15
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Pervaiz SS, Douglas SJ, Sax OC, Nabet A, Monarrez RG, Remily EA, Novack T, Nace J, Delanois RE. Phenotypic Frailty Score Predicts Perioperative Outcomes for Geriatric Total Joint Arthroplasty. Orthopedics 2022; 45:e315-e320. [PMID: 35947458 DOI: 10.3928/01477447-20220805-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Various assessment tools are often used to predict perioperative morbidity among patients older than 75 years who undergo total joint arthroplasty. Yet, few studies describe the use of phenotypic frailty as a predictor for outcomes. The goal of this study was to assess phenotypic frailty with the Sinai Abbreviated Geriatric Evaluation (SAGE) and compare its utility with established assessment tools used in practice. We specifically asked: (1) Can SAGE predict 30-day outcomes, including postoperative delirium? (2) Can SAGE determine the risk of prolonged hospital length of stay? (3) Is SAGE predictive for 30-day readmissions? (4) Can SAGE determine the risk of discharge to a specialized facility? Patients undergoing total hip arthroplasty and total knee arthroplasty were evaluated with the American Association of Anesthesiologists Physical Status (ASA), Charlson Comorbidity Index (CCI), 5-point Modified Frailty Score (5-FS), and SAGE. Assessment scores were determined for each patient, and every incremental change in score was used to predict the likelihood of perioperative complications. A receiver operating characteristic analysis was also performed to calculate testing sensitivity for each assessment tool. The SAGE scores were more likely to predict 30-day complications (odds ratio [95 CI], 2.21 [1.32-3.70]), postoperative delirium (6.40 [1.78-23.03]), and length of stay greater than 2 days (3.90 [1.00-15.7]) compared with ASA, CCI, and 5-FS values. The SAGE scores were not predictive of readmission (1.77 [0.66-4.72]) or discharge to a specialized facility (1.48 [0.80-2.75]). The SAGE score was a more sensitive predictor (area under the curve, 0.700) for perioperative morbidity compared with ASA (0.638), CCI (0.662), and 5-FS (0.644) values. Therefore, SAGE scores can reliably assess risk of perioperative morbidity and may have better clinical utility than ASA, CCI, and 5-FS values for patients undergoing total joint arthroplasty. [Orthopedics. 2022;45(6):e315-e320.].
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16
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Cechinel C, Lenardt MH, Rodrigues JAM, Binotto MA, Aristides MM, Kraus R. Frailty and delirium in hospitalized older adults: A systematic review with meta-analysis. Rev Lat Am Enfermagem 2022; 30:e3687. [PMID: 36287400 PMCID: PMC9580989 DOI: 10.1590/1518-8345.6120.3687] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/17/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to estimate the prevalence and synthesize diverse evidence about the relationship between frailty and delirium in hospitalized older adults. METHOD a systematic review with meta-analysis in which observational studies conducted with older adults about frailty, delirium and hospitalization, were selected without time of language restrictions. The search was conducted in the MEDLINE, EMBASE, CINAHL, Scopus, Web of Science and CENTRAL databases during August 2021. The precepts set forth by the Joanna Briggs Institute (JBI) - Evidence Synthesis Groups were followed. The meta-analysis model estimated the relative risk corresponding to the prevalence of frailty and delirium. The inverse variance method for proportions was used to estimate the prevalence values and relative risks for binary outcomes. RESULTS initially, 1,244 articles were identified, of which 26 were included in the meta-analysis (n=13,502 participants), with 34% prevalence of frailty (95% CI:0.26-0.42; I 2=99%; t 2=0.7618, p=0) and 21% for delirium (95% CI:0.17-0,25; I 2=95%; t 2=0.3454, p<0.01). The risk for hospitalized older adults to develop delirium was 66% (RR: 1.66; 95% CI:1.23-2.22; I2=92%; t2=0.4154; p<0.01). CONCLUSION 34% prevalence of frailty and 21% of delirium in hospitalized older adults, with frailty being an independent risk factor for developing delirium, with an increased chance of 66% when compared to non-frail individuals.
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Affiliation(s)
- Clovis Cechinel
- Universidade Federal do Paraná, Curitiba, PR, Brazil.,Secretaria Municipal de Saúde, Hospital Municipal do Idoso Zilda Arns, Curitiba, PR, Brazil
| | | | | | - Maria Angélica Binotto
- Universidade Estadual do Centro-Oeste, Departamento de Educação Fisica, Irati, PR, Brazil
| | | | - Rosane Kraus
- Universidade Federal do Paraná, Curitiba, PR, Brazil., Fundação Estatal de Atencão a Saúde, Hospital Municipal do Idoso Zilda Arns, Curitiba, PR, Brazil
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17
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Kubitz JC, Schubert AM, Schulte-Uentrop L. [Enhanced recovery after surgery (ERAS®) in cardiac anesthesia]. DIE ANAESTHESIOLOGIE 2022; 71:663-673. [PMID: 35987897 DOI: 10.1007/s00101-022-01190-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/19/2022] [Indexed: 06/15/2023]
Abstract
Enhanced Recovery After Cardiac Surgery (ERACS) is a multidisciplinary and multiprofessional treatment approach in cardiac surgery. Recently, a transfer and adaptation of enhanced recovery after surgery (ERAS) protocols from other disciplines, such as colorectal surgery, to cardiac surgery has been performed in different settings. First, prehabilitation programs have been established and investigated to improve patients' physical, psychological and nutritional status including treatment of preoperative anemia. Second, intraoperative therapeutic steps are described, such as infection reduction bundles, rigid sternal closure and guidance of perioperative anesthesia. For this, the use of short-acting agents, goal-directed fluid management and multimodal anesthesia are among the important measures. Third, early recovery and restoration of patient autonomy are achieved with early extubation and mobilization, efficient postoperative analgesia and diagnosis and treatment of delirium.The introduction of an ERACS protocol is a team effort requiring a protocol adapted to the institutional conditions and a willingness to perform a shift of culture in perioperative care. So far, the successful establishment of ERACS protocols in minimally invasive cardiac surgery has been reported and encourages the development of protocols of specific patient groups, such as pediatric cardiac surgery or left ventricular assist device implantation.
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Affiliation(s)
- J C Kubitz
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Nürnberg und Krankenhäuser Nürnberger Land GmbH, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Prof. Ernst Nathan Str. 1, 90419, Nürnberg, Deutschland.
| | - A-M Schubert
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - L Schulte-Uentrop
- Klinik und Poliklinik für Anästhesiologie, Zentrum für Anästhesiologie und Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
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Milne B, Lucas de Carvalho J, Ayis S, Chaubey S, Khan H, Kunst G. Frailty and perioperative patient-reported disability in patients undergoing cardiac surgery: a pilot study. Br J Anaesth 2022; 128:949-958. [PMID: 35465950 PMCID: PMC9204662 DOI: 10.1016/j.bja.2022.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 02/06/2022] [Accepted: 03/04/2022] [Indexed: 11/16/2022] Open
Abstract
Background Methods Results Conclusions
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthesia & Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Joshua Lucas de Carvalho
- Department of Anaesthesia & Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Salma Ayis
- Department of Statistics, School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, UK
| | - Sanjay Chaubey
- Department of Cardiothoracic Surgery, King's College NHS Foundation Trust, London, UK
| | - Habib Khan
- Department of Cardiothoracic Surgery, King's College NHS Foundation Trust, London, UK
| | - Gudrun Kunst
- Department of Anaesthesia & Pain Medicine, King's College Hospital NHS Foundation Trust, London, UK; British Heart Foundation Centre of Research Excellence, School of Cardiovascular Medicine & Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK.
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Wleklik M, Denfeld Q, Lisiak M, Czapla M, Kałużna-Oleksy M, Uchmanowicz I. Frailty Syndrome in Older Adults with Cardiovascular Diseases-What Do We Know and What Requires Further Research? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042234. [PMID: 35206422 PMCID: PMC8872246 DOI: 10.3390/ijerph19042234] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/08/2022] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
Abstract
Cardiovascular diseases (CVD) affect 60% of people over 60 years of age and are one of the main causes of death in the world. Diagnosed cardiovascular disease also triples the likelihood of Frailty syndrome (FS). FS has become increasingly relevant in cardiology and cardiac surgery and occurs in a significant number of patients with CVD, with prevalence ranging from 25% to 62%. Viewed in a multidimensional, biopsychosocial perspective, FS increases a patient's vulnerability, making them susceptible to several adverse clinical outcomes. Frailty syndrome also is a predictor of mortality in patients with CVD regardless of age, severity of disease, multi-morbidity, and disability. Frailty syndrome potentially can be prevented in patients with CVD and its early identification is important to avoid the development of disability, dependence on others and reduced quality of life. The aim of this paper is to show the relationship between FS and specific CVDs (coronary artery disease, hypertension, atrial fibrillation, heart failure) and cardiac procedures (device implantation, cardiac surgery, and transcatheter aortic valve implantation). Furthermore, we highlight those areas that require further research to fully understand the relationship between FS and CVD and to be able to minimize or prevent its adverse effects.
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Affiliation(s)
- Marta Wleklik
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Quin Denfeld
- School of Nursing, Oregon Health and Science University, Portland, OR 97239, USA;
| | - Magdalena Lisiak
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
| | - Michał Czapla
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
- Laboratory for Experimental Medicine and Innovative Technologies, Department of Emergency Medical Service, Wroclaw Medical University, 51-616 Wroclaw, Poland
- Correspondence:
| | - Marta Kałużna-Oleksy
- 1st Department of Cardiology, University of Medical Sciences in Poznan, 61-848 Poznan, Poland;
| | - Izabella Uchmanowicz
- Department of Nursing and Obstetrics, Faculty of Health Sciences, Wroclaw Medical University, 51-618 Wroclaw, Poland; (M.W.); (M.L.); (I.U.)
- Institute of Heart Diseases, University Hospital, 50-566 Wroclaw, Poland
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20
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Association between frailty and postoperative delirium: a meta-analysis of cohort study. Aging Clin Exp Res 2022; 34:25-37. [PMID: 33834367 DOI: 10.1007/s40520-021-01828-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Accepted: 03/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Frailty has been suggested as a possible risk factor for postoperative delirium (POD). However, results of previous studies were not consistent. We performed a meta-analysis of cohort study to evaluate the above association. METHODS Relevant studies were obtained via systematic search of PubMed, Embase, SCOPUS, and Web of Science databases. Only studies with multivariate analysis were included. A random-effect model incorporating the potential heterogeneity was used to combine the results. RESULTS Fifteen cohort studies including 3250 adult patients who underwent surgery were included, and the prevalence of frailty was 27.1% (880/3250) before surgeries. Overall, POD occurred in 513 patients (15.8%). Pooled results showed that frailty was associated with a higher risk of POD (adjusted odds ratio [OR]: 3.23, 95% confidence interval [CI]: 2.56-4.07, P < 0.001) without significant heterogeneity (P for Cochrane's Q test = 0.25, I2 = 18%). Subgroup analyses showed a more remarkable association between frailty and POD in prospective cohort studies (OR: 3.64, 95% CI: 2.95-4.49, P < 0.001) than that in retrospective cohort studies (OR: 2.32, 95% CI: 1.60-3.35, P < 0.001; P for subgroup difference = 0.04). Moreover, the association was not affected by country of the study, age group of the patient, elective or emergency surgeries, cardiac and non-cardiac surgeries, evaluation instruments for frailty, diagnostic methods for POD, or quality score of the study (P for subgroup difference all > 0.05). CONCLUSIONS Frailty may be associated with a higher risk of POD in adult population.
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Cechinel C, Lenardt MH, Rodrigues JAM, Binotto MA, Aristides MM, Kraus R. Fragilidad y delirium en adultos mayores hospitalizados: revisión sistemática con metanálisis. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.6120.3686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Resumen Objetivo: estimar la prevalencia y sintetizar evidencias sobre la relación entre fragilidad y delirium en adultos mayores hospitalizados. Método: revisión sistemática con metanálisis en el que se seleccionaron estudios observacionales realizados con adultos mayores sobre fragilidad, delirium y hospitalización, sin recorte temporal ni de idioma. La búsqueda se realizó en las bases de datos MEDLINE, EMBASE, CINAHL, Scopus, Web of Science y CENTRAL en agosto de 2021. Se siguieron los preceptos del Instituto Joanna Briggs (Joanna Briggs Institute, JBI) - Evidence Synthesis Groups. El modelo de metanálisis estimó el riesgo relativo de la prevalencia de fragilidad y delirium. Se utilizó el método de la varianza inversa para proporciones para estimar la prevalencia y el riesgo relativo de los desenlaces binarios. Resultados: inicialmente se identificaron 1.244 artículos, se incluyen en el metanálisis 26 (n=13.502 participantes), la prevalencia de fragilidad fue del 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) y de delirium del 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). El riesgo de que el adulto mayor frágil hospitalizado desarrolle delirium fue del 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusión: los adultos mayores hospitalizados tienen una prevalencia de fragilidad del 34% y de delirium del 21%, la fragilidad es un factor de riesgo independiente para el desarrollo de delirium, cuando se compara a los frágiles con los no frágiles, la probabilidad de delirium de los primeros es de un 66% más.
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Affiliation(s)
- Clovis Cechinel
- Universidade Federal do Paraná, Brazil; Secretaria Municipal de Saúde, Brazil
| | | | | | | | | | - Rosane Kraus
- Universidade Federal do Paraná, Brazil; Fundação Estatal de Atencão a Saúde, Brazil
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Cechinel C, Lenardt MH, Rodrigues JAM, Binotto MA, Aristides MM, Kraus R. Fragilidade e delirium em idosos hospitalizados: revisão sistemática com metanálise. Rev Lat Am Enfermagem 2022. [DOI: 10.1590/1518-8345.6120.3688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Resumo Objetivo: estimar a prevalência e sintetizar evidências sobre a relação entre fragilidade e delirium em idosos hospitalizados. Método: revisão sistemática com metanálise na qual foram selecionados estudos observacionais realizados com idosos sobre fragilidade, delirium e hospitalização, sem recortes temporais e de idioma. A busca foi realizada nas bases de dados MEDLINE, EMBASE, CINAHL, Scopus, Web of Science e CENTRAL durante o mês de agosto de 2021. Foram seguidos os preceitos estabelecidos pelo Joanna Briggs Institute (JBI) - Grupos de Síntese de Evidências.. O modelo de metanálise estimou risco relativo da prevalência de fragilidade e delirium. Utilizou-se método da variância inversa para proporções para estimar as prevalências e risco relativo para desfechos binários. Resultados: identificaram-se, inicialmente, 1.244 artigos, 26 incluídos na metanálise (n=13.502 participantes), sendo a prevalência de fragilidade 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) e delirium 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). O risco do idoso frágil hospitalizado desenvolver delirium foi de 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusão: prevalência de 34% de fragilidade e 21% de delirium em idosos hospitalizados, sendo a fragilidade um fator de risco independente para desenvolvimento de delirium, com um aumento de chance de 66% comparado aos não frágeis.
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Affiliation(s)
- Clovis Cechinel
- Universidade Federal do Paraná, Brazil; Secretaria Municipal de Saúde, Brazil
| | | | | | | | | | - Rosane Kraus
- Universidade Federal do Paraná, Brazil; Fundação Estatal de Atencão a Saúde, Brazil
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O’Gara BP, Gao L, Marcantonio ER, Subramaniam B. Sleep, Pain, and Cognition: Modifiable Targets for Optimal Perioperative Brain Health. Anesthesiology 2021; 135:1132-1152. [PMID: 34731233 PMCID: PMC8578455 DOI: 10.1097/aln.0000000000004046] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The prevention of perioperative neurocognitive disorders is a priority for patients, families, clinicians, and researchers. Given the multiple risk factors present throughout the perioperative period, a multicomponent preventative approach may be most effective. The objectives of this narrative review are to highlight the importance of sleep, pain, and cognition on the risk of perioperative neurocognitive disorders and to discuss the evidence behind interventions targeting these modifiable risk factors. Sleep disruption is associated with postoperative delirium, but the benefit of sleep-related interventions is uncertain. Pain is a risk factor for postoperative delirium, but its impact on other postoperative neurocognitive disorders is unknown. Multimodal analgesia and opioid avoidance are emerging as best practices, but data supporting their efficacy to prevent delirium are limited. Poor preoperative cognitive function is a strong predictor of postoperative neurocognitive disorder, and work is ongoing to determine whether it can be modified to prevent perioperative neurocognitive disorders.
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Affiliation(s)
- Brian P O’Gara
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
| | - Lei Gao
- Massachusetts General Hospital. Department of Anesthesia. Harvard Medical School. Boston, MA, USA
| | - Edward R Marcantonio
- Beth Israel Deaconess Medical Center. Department of Medicine. Harvard Medical School. Boston, MA, USA
| | - Balachundhar Subramaniam
- Beth Israel Deaconess Medical Center. Department of Anesthesiology, Critical Care and Pain Medicine. Harvard Medical School. Boston, MA, USA
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24
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Riley KJ, Kao LW, Low YH, Card S, Manalo G, Fleming JP, Essandoh MK, Dalia AA, Qu JZ. Neurologic Dysfunction and Neuroprotection in Transcatheter Aortic Valve Implantation. J Cardiothorac Vasc Anesth 2021; 36:3224-3236. [PMID: 34903454 DOI: 10.1053/j.jvca.2021.11.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 11/11/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) is a fast-growing procedure. Expanding to low-risk patients, it has surpassed surgical aortic valve implantation in frequency and has been associated with excellent outcomes. Stroke is a devastating complication after transcatheter aortic valve implantation. Silent brain infarcts identified by diffusion-weighted magnetic resonance imaging are present in most patients following TAVI. Postoperative delirium and cognitive dysfunction are common neurologic complications. The stroke and silent brain infarcts are likely caused by particulate emboli released during the procedure. Intravascularly positioned cerebral embolic protection devices are designed to prevent debris from entering the aortic arch vessels to avoid stroke. Despite promising design, randomized clinical trials have not demonstrated a reduction in stroke in patients receiving cerebral embolic protection devices. Similarly, the association of cerebral embolic protection devices with silent brain infarcts, postoperative delirium, and cognitive dysfunction is uncertain. Monitored anesthesia care or conscious sedation is as safe as general anesthesia and is associated with lower cost, but different anesthetic techniques have not been shown to decrease stroke risk, postoperative delirium, or cognitive dysfunction. Anesthesiologists play important roles in providing perioperative care including management of neurologic events in patients undergoing TAVI. Large randomized clinical trials are needed that focus on the correlation between perioperative interventions and neurologic outcomes.
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Affiliation(s)
- Kyle J Riley
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Lee-Wei Kao
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ying H Low
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Shika Card
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Gem Manalo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jeffrey P Fleming
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Michael K Essandoh
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, OH
| | - Adam A Dalia
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
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25
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Liu CY, Gong N, Liu W. The Association Between Preoperative Frailty and Postoperative Delirium: A Systematic Review and Meta-analysis. J Perianesth Nurs 2021; 37:53-62.e1. [PMID: 34756625 DOI: 10.1016/j.jopan.2020.12.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/13/2020] [Accepted: 12/26/2020] [Indexed: 12/23/2022]
Abstract
PURPOSE Identifying factors that place patients at high risk for developing postoperative delirium is an important first step to reduce incidence. Frailty is associated with poor postoperative outcomes. This meta-analysis aims to determine the association between preoperative frailty and postoperative delirium. DESIGN This is a systematic review and meta-analysis. METHODS We used PubMed, Scopus, Embase, CINAHL, Cochrane, and Web of Science as databases for the search up to April 23, 2020. We included cohort studies that assessed postoperative delirium as the outcome and described the prevalence of delirium among participants during the postoperative period. Odds ratio and 95% confidence interval were calculated to examine the association. FINDINGS Twenty cohort studies met our inclusion criteria, which included a total of 4,568 patients. We found that preoperative frailty was significantly associated with an increased risk of postoperative delirium (crude odds ratio: 3.28; 95% confidence interval: 2.51 to 4.28; I2 = 46.7%) (adjusted odds ratio: 2.45; 95% confidence interval: 1.58 to 3.81; I2 = 88.6%). CONCLUSIONS This meta-analysis showed that preoperative frailty is an independent risk factor for postoperative delirium. In patients undergoing cardiovascular surgery, there is a lower association between frailty and postoperative delirium. In patients with other types of surgery, preoperative frailty is closely related to postoperative delirium.
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Affiliation(s)
- Chang-Yuan Liu
- The Second Department of Anesthesiology, Affiliated Zhongshan Hospital of Dalian University, Dalian, Liaoning, China
| | - Ning Gong
- Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Liu
- School of Nursing, Liaoning University of Traditional Chinese Medicine, Shenyang, Liaoning, China.
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26
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Gracie TJ, Caufield-Noll C, Wang NY, Sieber FE. The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis. Anesth Analg 2021; 133:314-323. [PMID: 34257192 DOI: 10.1213/ane.0000000000005609] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Both frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD. METHODS We searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05. RESULTS Nine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias. CONCLUSIONS This meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.
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Affiliation(s)
- Thomas J Gracie
- From the Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christine Caufield-Noll
- Library Services, Harrison Library, Johns Hopkins Bayview Medical Center, Baltimore, Maryland
| | - Nae-Yuh Wang
- Departments of Medicine (General Internal Medicine), Biostatistics, and Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Frederick E Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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27
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Zhang XM, Jiao J, Xie XH, Wu XJ. The Association Between Frailty and Delirium Among Hospitalized Patients: An Updated Meta-Analysis. J Am Med Dir Assoc 2021; 22:527-534. [PMID: 33549566 DOI: 10.1016/j.jamda.2021.01.065] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/12/2021] [Accepted: 01/13/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The aim of our meta-analysis was to update evidence for the association between frailty and delirium in different types of hospitalized patients, given the large volume of new studies with inconsistent results. DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS In this updated meta-analysis, we searched 3 databases (Embase, PubMed, and the Cochrane Library) for observational studies, exploring the association between frailty and delirium from database inception to September 21, 2020, among hospitalized patients. Relevant data were extracted from the studies that were included. A random effects model was conducted to synthesize and pool the effect size of frailty on delirium due to different frailty score instruments, different countries, and various delirium assessments that were used. The participants enrolled in this meta-analysis were hospitalized patients. MEASURES Delirium risk due to frailty. RESULTS A total of 30 independent studies from 9 countries, consisting of 217,623 patients, was identified, and the prevalence of frailty ranged from 16.20% to 78.00%. Frail patients exhibited an increased risk for delirium compared to those without frailty [odds ratio (OR) 2.96, 95% confidence interval (CI) 2.36-3.71]. In addition, different types of hospitalized patients had various OR values, which were 2.43 for selective surgical patients (95% CI 1.88-3.14), 3.61 for medical patients (95% CI 3.61-7.89), 3.76 for urgent surgical patients (95% CI 2.88-4.92), and 6.66 for emergency or critical illness patients (95% CI 1.41-31.47). Subgroup analysis based on the frailty score instrument showed the association still existed when using the Clinical Frailty Scale (OR 4.07, 95% CI 2.71-6.11), FRAIL Scale (OR 2.83, 95% CI 1.56-5.13), Frailty Index (OR 6.15, 95% CI 3.75-10.07), frailty phenotype (OR 2.30, 95%CI 1.35-5.66), or Erasmus Frailty Score (OR 2.79, 95% CI 1.63-4.77). However, an association between frailty and delirium was not observed when the Edmonton Frail Scale was used (OR 1.45, 95% CI 0.91-2.30). CONCLUSIONS AND IMPLICATIONS A 2.96-fold incremental risk of delirium in frail patients underscores the need for early screening of frailty and comprehensive delirium prevention. Appropriate interventions by clinicians should be performed to manage delirium, potentially reducing adverse clinical outcomes for hospitalized patients.
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Affiliation(s)
- Xiao-Ming Zhang
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Jing Jiao
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China
| | - Xiao-Hua Xie
- Shenzhen Second People's Hospital, Shenzhen, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences-Peking Union Medical College, Peking Union Medical College Hospital (Dongdan Campus), Beijing, China.
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28
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Neuroanesthesiology Update. J Neurosurg Anesthesiol 2021; 33:107-136. [PMID: 33480638 DOI: 10.1097/ana.0000000000000757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Accepted: 12/18/2020] [Indexed: 11/27/2022]
Abstract
This review summarizes the literature published in 2020 that is relevant to the perioperative care of neurosurgical patients and patients with neurological diseases as well as critically ill patients with neurological diseases. Broad topics include general perioperative neuroscientific considerations, stroke, traumatic brain injury, monitoring, anesthetic neurotoxicity, and perioperative disorders of cognitive function.
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29
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Shanker A, Upadhyay P, Rangasamy V, Muralidhar K, Subramaniam B. Impact of frailty in cardiac surgical patients-Assessment, burden, and recommendations. Ann Card Anaesth 2021; 24:133-139. [PMID: 33884967 PMCID: PMC8253036 DOI: 10.4103/aca.aca_90_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Elderly patients undergoing cardiac surgery are at an increased risk of adverse postoperative outcomes. Frailty, a state of decreased physiological reserve, is highly prevalent among elderly patients. Despite being associated with adverse surgical outcomes, no universally accepted definition or measurement tool for frailty exists. Moreover, regardless of all the recommendations, a routine perioperative frailty assessment is often ignored. In addition to complications, frailty increases the burden to the healthcare system, which is of particular concern in Southeast Asia due to its socioeconomically disadvantaged and resource limited settings. This narrative review focuses to develop clinical practice plans for perioperative frailty assessment in the context of a cardiac surgical setting.
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Affiliation(s)
- Akshay Shanker
- Department of Anesthesia, Critical Care, and Pain Medicine, Lewis Katz School of Medicine at Temple University, 3500 North Broad St., Philadelphia, Pennsylvania; Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Preeti Upadhyay
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Valluvan Rangasamy
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - Kanchi Muralidhar
- Department of Anesthesia, Narayana Institute of Cardiac Sciences, Narayana Hrudayalaya Health City, Bengaluru, Karnataka, India
| | - Balachundhar Subramaniam
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
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30
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Rockwood K, Andrew MK, Aubertin‐Leheudre M, Belleville S, Bherer L, Bowles SK, Kehler DS, Lim A, Middleton L, Phillips N, Wallace LM. CCCDTD5: Reducing the risk of later-life dementia. Evidence informing the Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5). ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2020; 6:e12083. [PMID: 33204818 PMCID: PMC7656906 DOI: 10.1002/trc2.12083] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 11/23/2022]
Abstract
The Fifth Canadian Consensus Conference on the Diagnosis and Treatment of Dementia (CCCDTD-5) was a year-long process to synthesize the best available evidence on several topics. Our group undertook evaluation of risk reduction, in eight domains: nutrition; physical activity; hearing; sleep; cognitive training and stimulation; social engagement and education; frailty; and medications. Here we describe the rationale for the undertaking and summarize the background evidence-this is also tabulated in the Appendix. We further comment specifically on the relationship between age and dementia, and offer some suggestions for how reducing the risk of dementia in the seventh decade and beyond might be considered if we are to improve prospects for prevention in the near term. We draw to attention that a well-specified model of success in dementia prevention need not equate to the elimination of cognitive impairment in late life.
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Affiliation(s)
- Kenneth Rockwood
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | - Melissa K. Andrew
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
| | | | - Sylvie Belleville
- Research CenterInstitut Universitaire de Gériatrie de MontréalMontréalQuebecCanada
- Psychology DepartmentUniversité de MontréalMontréalCanada
| | - Louis Bherer
- Département de Médecine, Faculté de médecine, Université de Montréal, Centre de recherche, Institut de cardiologie de Montréal, Centre de rechercheInstitut universitaire de gériatrie de MontréalMontréalQuébecCanada
| | - Susan K. Bowles
- Division of Geriatric MedicineDalhousie UniversityHalifaxNova ScotiaCanada
- College of PharmacyDalhousie UniversityHalifaxNova ScotiaCanada
| | - D Scott Kehler
- School of PhysiotherapyDalhousie UniversityHalifaxNova ScotiaCanada
| | - Andrew Lim
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences CentreUniversity of TorontoTorontoOntarioCanada
| | - Laura Middleton
- Department of KinesiologyUniversity of WaterlooWaterlooOntarioCanada
| | - Natalie Phillips
- Department of PsychologyConcordia UniversityMontréalQuébecCanada
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Abstract
Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.
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32
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De Biasio JC, Mittel AM, Mueller AL, Ferrante LE, Kim DH, Shaefi S. Frailty in Critical Care Medicine: A Review. Anesth Analg 2020; 130:1462-1473. [PMID: 32384336 DOI: 10.1213/ane.0000000000004665] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Traditional approaches to clinical risk assessment utilize age as a marker of increased vulnerability to stress. Relatively recent advancements in the study of aging have led to the concept of the frailty syndrome, which represents a multidimensional state of depleted physiologic and psychosocial reserve and clinical vulnerability that is related to but variably present with advancing age. The frailty syndrome is now a well-established clinical entity that serves as both a guide for clinical intervention and a predictor of poor outcomes in the primary and acute care settings. The biological aspects of the syndrome broadly represent a network of interrelated perturbations involving the age-related accumulation of molecular, cellular, and tissue damage that leads to multisystem dysregulation, functional decline, and disproportionately poor response to physiologic stress. Given the complexity of the underlying biologic processes, several well-validated approaches to define frailty clinically have been developed, each with distinct and reasonable considerations. Stemming from this background, the past several years have seen a number of observational studies conducted in intensive care units that have established that the determination of frailty is both feasible and prognostically useful in the critical care setting. Specifically, frailty as determined by several different frailty measurement tools appears associated with mortality, increased health care utilization, and disability, and has the potential to improve risk stratification of intensive care patients. While substantial variability in the implementation of frailty measurement likely limits the generalizability of specific findings, the overall prognostic trends may offer some assistance in guiding management decisions with patients and their families. Although no trials have assessed interventions to improve the outcomes of critically ill older people living with frailty, the particular vulnerability of this population offers a promising target for intervention in the future.
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Affiliation(s)
- Justin C De Biasio
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Aaron M Mittel
- Department of Anesthesiology, Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York, New York
| | - Ariel L Mueller
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Lauren E Ferrante
- Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Dae H Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts
| | - Shahzad Shaefi
- From the Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
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33
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Abstract
BACKGROUND Although frailty has been associated with major morbidity/mortality and increased length of stay after cardiac surgery, few studies have examined functional outcomes. We hypothesized that frailty would be independently associated with decreased functional status, increased discharge to a nonhome location, and longer duration of hospitalization after cardiac surgery, and that delirium would modify these associations. METHODS This was an observational study nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. The Fried frailty scale was measured at baseline. The primary outcome (defined before data collection) was functional decline, defined as ≥2-point decline from baseline in Instrumental Activities of Daily Living (IADL) score at 1 month after surgery. Secondary outcomes were absolute decline in IADL score, discharge to a new nonhome location, and duration of hospitalization. Associations were analyzed using linear, logistic, and Poisson regression models with adjustments for variables considered before analysis (age, gender, race, and logistic European Score for Cardiac Operative Risk Evaluation [EuroSCORE]) and in a propensity score analysis. RESULTS Data were available from 133 patients (83 from first trial and 50 from the second trial). The prevalence of frailty was 33% (44 of 133). In adjusted models, frail patients had increased odds of functional decline (primary outcome; odds ratio [OR], 2.41 [95% confidence interval {CI}, 1.03-5.63]; P = .04) and greater decline at 1 month in the secondary outcome of absolute IADL score (-1.48 [95% CI, -2.77 to -0.30]; P = .019), compared to nonfrail patients. Delirium significantly modified the association of frailty and change in absolute IADL score at 1 month. In adjusted hypothesis-generating models using secondary outcomes, frail patients had increased discharge to a new nonhome location (OR, 3.25 [95% CI, 1.37-7.69]; P = .007) and increased duration of hospitalization (1.35 days [95% CI, 1.19-1.52]; P < .0001) compared to nonfrail patients. The increased duration of hospitalization, but no change in functional status or discharge location, was partially mediated by increased complications in frail patients. CONCLUSIONS Frailty may identify patients at risk of functional decline at 1 month after cardiac surgery. Perioperative strategies to optimize frail cardiac surgery patients are needed.
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Mahanna-Gabrielli E, Zhang K, Sieber FE, Lin HM, Liu X, Sewell M, Deiner SG, Boockvar KS. Frailty Is Associated With Postoperative Delirium But Not With Postoperative Cognitive Decline in Older Noncardiac Surgery Patients. Anesth Analg 2020; 130:1516-1523. [PMID: 32384341 PMCID: PMC7875454 DOI: 10.1213/ane.0000000000004773] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery. METHODS We performed a prospective cohort study of patients >65 years old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial, or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire that categorizes patients as robust, prefrail, or frail. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Examination) before surgery and at 3 months afterward. RESULTS A total of 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow-up 3 months after surgery. The median age was 70 years old. Thirty-one patients (18.6%) tested as frail, and 72 (43.1%) prefrail before surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiologists (ASA) physical status, type of surgery, and sex, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval, 1.0-7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail, or robust. CONCLUSIONS After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL scale is associated with increased odds of postoperative delirium, but not POCD after noncardiac surgery.
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Affiliation(s)
- Elizabeth Mahanna-Gabrielli
- From the Department of Anesthesiology, Perioperative and Pain Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Kathy Zhang
- Rutgers New Jersey Medical School, Newark, New Jersey
| | - Frederick E Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hung Mo Lin
- Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Xiaoyu Liu
- Departments of Anesthesiology, Perioperative and Pain Medicine
| | | | - Stacie G Deiner
- Anesthesiology, Perioperative and Pain Medicine, Neurosurgery, Geriatrics and Palliative Care
| | - Kenneth S Boockvar
- Geriatrics and Palliative Care, Icahn School of Medicine at Mount Sinai, New York, New York
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Damluji AA, Forman DE, van Diepen S, Alexander KP, Page RL, Hummel SL, Menon V, Katz JN, Albert NM, Afilalo J, Cohen MG. Older Adults in the Cardiac Intensive Care Unit: Factoring Geriatric Syndromes in the Management, Prognosis, and Process of Care: A Scientific Statement From the American Heart Association. Circulation 2020; 141:e6-e32. [DOI: 10.1161/cir.0000000000000741] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Longevity is increasing, and more adults are living to the stage of life when age-related biological factors determine a higher likelihood of cardiovascular disease in a distinctive context of concurrent geriatric conditions. Older adults with cardiovascular disease are frequently admitted to cardiac intensive care units (CICUs), where care is commensurate with high age-related cardiovascular disease risks but where the associated geriatric conditions (including multimorbidity, polypharmacy, cognitive decline and delirium, and frailty) may be inadvertently exacerbated and destabilized. The CICU environment of procedures, new medications, sensory overload, sleep deprivation, prolonged bed rest, malnourishment, and sleep is usually inherently disruptive to older patients regardless of the excellence of cardiovascular disease care. Given these fundamental and broad challenges of patient aging, CICU management priorities and associated decision-making are particularly complex and in need of enhancements. In this American Heart Association statement, we examine age-related risks and describe some of the distinctive dynamics pertinent to older adults and emerging opportunities to enhance CICU care. Relevant assessment tools are discussed, as well as the need for additional clinical research to best advance CICU care for the already dominating and still expanding population of older adults.
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Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39-47. [PMID: 31570245 DOI: 10.1053/j.jvca.2019.09.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Herzzentrum Leipzig, Leipzig, Germany
| | - Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, UKGM University Hospital Gießen, Justus-Liebig-University Giessen, Gießen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine and Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob T Gutsche
- Division of Cardiac Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Andre Denault
- Département d'Anesthésiologie et de Médecine de la Douleur, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Division des Soins Intensifs, Département de Chirurgie Cardiaque, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Département de Pharmacologie et de Physiologie, Institut de Cardiologie de Montréal, Montréal, Quebec Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nick Fletcher
- Department of Cardiothoracic Anesthesia and Critical Care, St. Georges University Hospital, London, United Kingdom; Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
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