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Barreto Chang OL, Pawar N, Whitlock EL, Miller B, Possin KL. Gaps in cognitive care among older patients undergoing spine surgery. J Am Geriatr Soc 2024. [PMID: 38407475 DOI: 10.1111/jgs.18843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/12/2024] [Accepted: 02/08/2024] [Indexed: 02/27/2024]
Abstract
INTRODUCTION Among older adults undergoing surgery, postoperative delirium is the most common complication. Cognitive impairment and dementia are major risk factors for postoperative delirium, yet they are frequently under-recognized. It is well established that applying delirium preventive interventions to at-risk individuals can reduce the likelihood of delirium by up to 40%. The aim of this study was to evaluate how often delirium preventive interventions are missing in patients at risk for delirium due to baseline cognitive impairment. METHODS We conducted a retrospective study using data from the observational study Perioperative Anesthesia Neurocognitive Disorder Assessment-Geriatric (PANDA-G) and clinical data from the University of California San Francisco delirium prevention bundle. Patients age 65+ received preoperative multidomain cognitive assessment as part of a research protocol prior to undergoing inpatient spine surgery at a single major academic institution. Results of the cognitive testing were not available to clinical teams. Using electronic medical records, we evaluated if patients who were cognitively impaired at baseline received delirium prevention orders, sleep orders, and avoidance of AGS Beers Criteria® potentially inappropriate medications. RESULTS Of the 245 patients included in the study, 42% were women. The mean [SD] age was 72 [5.2] years. Preoperative cognitive impairment was identified in 40% of participants (N = 98), and of these, 34% had postoperative delirium. Of patients with preoperative cognitive impairment, 45% did not receive delirium preventive orders, 43% received PIMs, and 49% were missing sleep orders. At least one of the three delirium preventive interventions was missing in 70% of the patients. DISCUSSION Undiagnosed preoperative cognitive impairment among older adults undergoing spine surgery is common. When cognitive test results were not available to clinicians, patients with baseline cognitive impairment frequently did not receive evidence-based delirium preventive interventions. These findings highlight an opportunity to improve perioperative brain health care via preoperative cognitive assessment and clinical communication.
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Affiliation(s)
- Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Niti Pawar
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Elizabeth L Whitlock
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, California, USA
| | - Bruce Miller
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California, USA
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California, USA
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Gisselbaek M, Hontoir S, Pesonen AE, Seidel L, Geniets B, Steen E, Barreto Chang OL, Saxena S. Impostor syndrome in anaesthesiology primarily affects female and junior physicians ☆. Br J Anaesth 2024; 132:407-409. [PMID: 37884406 DOI: 10.1016/j.bja.2023.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 09/26/2023] [Accepted: 09/27/2023] [Indexed: 10/28/2023] Open
Affiliation(s)
- Mia Gisselbaek
- Division of Anaesthesiology, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sonia Hontoir
- Department of Anaesthesiology UZ Brussel, Brussels, Belgium
| | | | - Laurence Seidel
- B-STAT, Biostatistics and Research Method Center of ULiège and CHU of Liège, Liege, Belgium
| | | | - Evi Steen
- Department of Anaesthesiology-Critical Care, Az Sint-Jan Brugge-Oostende AV, Bruges, Belgium
| | - Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, CA, USA
| | - Sarah Saxena
- Department of Anaesthesiology-Critical Care, Az Sint-Jan Brugge-Oostende AV, Bruges, Belgium.
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Shin SY, Goode CA, Bui NM, Premkumar M, Hill-Sakurai LE, Bernstein Sideman A, Kiekhofer RE, Chodos AH, Dulaney S, Wynn MJ, Barreto Chang OL, Possin KL. Addressing gaps in primary care diagnosis of cognitive impairment via a telephone-based nurse consultation. J Am Geriatr Soc 2023; 71:2002-2005. [PMID: 36705443 PMCID: PMC10258125 DOI: 10.1111/jgs.18258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023]
Affiliation(s)
- So Young Shin
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
- College of Nursing, Inje University, Busan, Korea
| | - Collette A. Goode
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Nhat M. Bui
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Mukund Premkumar
- Family Medicine Center at Lakeshore, Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Laura E. Hill-Sakurai
- Family Medicine Center at Lakeshore, Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Alissa Bernstein Sideman
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Rachel E. Kiekhofer
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Anna H. Chodos
- Division of Geriatrics, University of California, San Francisco, USA
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Matthew J. Wynn
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Odmara L. Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, USA
| | - Katherine L. Possin
- Global Brain Health Institute, University of California, San Francisco, San Francisco, CA, USA
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
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Barreto Chang OL, Maze M. Defining the role of Interleukin-6 for the development of perioperative neurocognitive disorders: Evidence from clinical and preclinical studies. Front Aging Neurosci 2023; 14:1097606. [PMID: 36778590 PMCID: PMC9908597 DOI: 10.3389/fnagi.2022.1097606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/31/2022] [Indexed: 01/27/2023] Open
Abstract
For most, staying "mentally sharp" as they age is a very high priority that may be thwarted by the consequences of a postoperative complication unrelated to the disorder which necessitated the surgical intervention. Perioperative neurocognitive disorder (PND) is an overarching term for cognitive impairment in surgical patients, that includes conditions from delirium to dementia, affecting more than 7 million patients annually in the US, and which threatens both functional independence and life. Clinical trials and meta-analyses have identified the association between PNDs and increased perioperative levels of Interleukin-6 (IL-6), a pleiotropic cytokine that is both necessary and sufficient for postoperative memory decline in a preclinical model of PND. Recently, we reported that, in adult male wild-type mice subjected to tibial fracture under general anesthesia, IL-6 trans-signaling in hippocampal CA1 neurons mediates surgery-induced memory impairment. As there are no therapeutic options for preventing or reversing PNDs, patients and their caregivers, as well as the healthcare industry, endure staggering costs. Olamkicept, a highly selective IL-6 trans-signaling blocker has shown to be efficacious and safe in clinical trials involving patients with inflammatory bowel disease, another condition for which IL-6 trans-signaling is the mediating mechanism. Subject to a demonstration that olamkicept is effective in preventing cognitive impairment in vulnerable (aged and Alzheimer's Disease) preclinical PND models, clinical trials involving aged and/or cognitively impaired surgical patients should be undertaken to study olamkicept's utility for PNDs.
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Affiliation(s)
- Odmara L. Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, San Francisco, CA, United States
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, Center for Cerebrovascular Disease, University of California, San Francisco, San Francisco, CA, United States,*Correspondence: Mervyn Maze, ✉
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Barreto Chang OL, Possin KL, Maze M. Age-Related Perioperative Neurocognitive Disorders: Experimental Models and Druggable Targets. Annu Rev Pharmacol Toxicol 2023; 63:321-340. [PMID: 36100220 DOI: 10.1146/annurev-pharmtox-051921-112525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
With the worldwide increase in life span, surgical patients are becoming older and have a greater propensity for postoperative cognitive impairment, either new onset or through deterioration of an existing condition; in both conditions, knowledge of the patient's preoperative cognitive function and postoperative cognitive trajectory is imperative. We describe the clinical utility of a tablet-based technique for rapid assessment of the memory and attentiveness domains required for executive function. The pathogenic mechanisms for perioperative neurocognitive disorders have been investigated in animal models in which excessive and/or prolonged postoperative neuroinflammation has emerged as a likely contender. The cellular and molecular species involved in postoperative neuroinflammation are the putative targets for future therapeutic interventions that are efficacious and do not interfere with the surgical patient's healing process.
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Affiliation(s)
- Odmara L Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA;
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, and Global Brain Health Institute, University of California San Francisco, San Francisco, California, USA
| | - Mervyn Maze
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California, USA; .,Center for Cerebrovascular Research, University of California San Francisco, San Francisco, California, USA
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Barreto Chang OL, Whitlock EL, Arias AD, Tsoy E, Allen IE, Hellman J, Bickler PE, Miller B, Possin KL. A novel approach for the detection of cognitive impairment and delirium risk in older patients undergoing spine surgery. J Am Geriatr Soc 2023; 71:227-234. [PMID: 36125032 PMCID: PMC9870968 DOI: 10.1111/jgs.18033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 07/28/2022] [Accepted: 08/16/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND Postoperative delirium is a common postsurgical complication in older patients and is associated with high morbidity and mortality. The objective of this study was to determine whether a digital cognitive assessment and patient characteristics could identify those at-risk. METHODS Patients 65 years and older undergoing spine surgeries ≥3 h were evaluated as part of a single-center prospective observational cohort study at an academic medical center, from January 1, 2019, to December 31, 2020. Of 220 eligible patients, 161 were enrolled and 152 completed the study. The primary outcome of postoperative delirium was measured by the Confusion Assessment Method for the Intensive Care Unit or the Nursing Delirium Screening Scale, administered by trained nursing staff independent from the study protocol. Baseline cognitive impairment was identified using the tablet-based TabCAT Brain Health Assessment. RESULTS Of the 152 patients included in this study, 46% were women. The mean [SD] age was 72 [5.4] years. Baseline cognitive impairment was identified in 38% of participants, and 26% had postoperative delirium. In multivariable analysis, impaired Brain Health Assessment Cognitive Score (OR 2.45; 95% CI, 1.05-5.67; p = 0.037), depression (OR 4.54; 95% CI, 1.73-11.89; p = 0.002), and higher surgical complexity Tier 4 (OR 5.88; 95% CI, 1.55-22.26; p = 0.009) were associated with postoperative delirium. The multivariate model was 72% accurate for predicting postoperative delirium, compared to 45% for the electronic medical record-based risk stratification model currently in use. CONCLUSION In this prospective cohort study of spine surgery patients, age, cognitive impairment, depression, and surgical complexity identified patients at high risk for postoperative delirium. Integration of scalable digital assessments into preoperative workflows could identify high-risk patients, automate decision support for timely interventions that can improve patient outcomes and lower hospital costs, and provide a baseline cognitive assessment to monitor for postoperative cognitive change.
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Affiliation(s)
- Odmara L. Barreto Chang
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Elizabeth L. Whitlock
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Aimee D. Arias
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Elena Tsoy
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
| | - Isabel E. Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Judith Hellman
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Philip E. Bickler
- Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Bruce Miller
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California
| | - Katherine L. Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California
- Global Brain Health Institute, University of California, San Francisco, San Francisco, California
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Barreto Chang OL, Kreuzer M, Morgen DF, Possin KL, García PS. Ketamine Associated Intraoperative Electroencephalographic Signatures of Elderly Patients With and Without Preoperative Cognitive Impairment. Anesth Analg 2022; 135:683-692. [PMID: 35051953 DOI: 10.1213/ane.0000000000005875] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Ketamine is typically used by anesthesiologists as an adjunct for general anesthesia and as a nonopioid analgesic. It has been explored for prevention of postoperative delirium, although results have been contradictory. In this study, we investigated the association of ketamine with postoperative delirium and specific encephalographic signatures. Furthermore, we examined these associations in the context of baseline neurocognition as measured by a validated assessment. METHODS We conducted a prospective observational study from January 2019 to December 2020. Ninety-eight patients aged ≥65 years and undergoing spine surgery scheduled for ≥3 hours were included in the study. All participants who completed the University of California San Francisco (UCSF) Brain Health Assessment preoperatively and postoperatively were assessed with the confusion assessment method for intensive care unit (CAM-ICU) and/or the Nursing Delirium Screening Scale (NuDESC). Patients had frontal electroencephalogram (EEG) recordings (SedLine Root, Masimo, Corp) quantitatively analyzed. We used 60 seconds of artifact-free EEG (without burst suppression) extracted from the middle of the maintenance period to calculate the normalized power spectral density (PSD). Comparisons were made between those who did or did not receive ketamine and according to results from neurocognitive assessments. RESULTS Ninety-eight patients (of a total of 155, enrolled and consented) had EEG of sufficient quality for analysis (42 women). Overall, we found a significant increase in the EEG power in the moderate frequency range (10-20 Hz) in patients that received ketamine. When the patients were divided by their preoperative cognitive status, this result in the ketamine group only held true for the cognitively normal patients. Patients that were cognitively impaired at baseline did not demonstrate a significant change in EEG characteristics based on ketamine administration, but impaired patients that received ketamine had a significantly higher rate of postoperative delirium (52% ketamine versus 20% no ketamine) (odds ratio [OR], 4.36; confidence interval [CI], 1.02-18.22; P = .048). In patients determined to be preoperatively cognitively normal, the incidence of postoperative delirium was not significantly associated with ketamine administration (19% ketamine versus 17% no ketamine) (OR, 1.10; CI, 0.30-4.04; P = .5833). CONCLUSIONS Ketamine-related changes in EEG are observed in a heterogeneous group of patients receiving spine surgery. This result was driven primarily by the effect of ketamine on cognitively normal patients and not observed in patients that were cognitively impaired at baseline. Furthermore, patients who were cognitively impaired at baseline and who had received ketamine were more likely to develop postoperative delirium, suggesting that cognitive vulnerability might be predicted by the lack of a neurophysiologic response to ketamine.
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Affiliation(s)
- Odmara L Barreto Chang
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Matthias Kreuzer
- Department of Anesthesiology and Intensive Care, Technical University of Munich, School of Medicine, Munich, Germany
| | - Danielle F Morgen
- From the Department of Anesthesia and Perioperative Care, University of California San Francisco, San Francisco, California
| | - Katherine L Possin
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, San Francisco, California.,Global Brain Health Institute, University of California, San Francisco, San Francisco, California
| | - Paul S García
- Department of Anesthesiology, Columbia University Medical Center New York Presbyterian Hospital, New York, New York
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Pawar N, Barreto Chang OL. Burst Suppression During General Anesthesia and Postoperative Outcomes: Mini Review. Front Syst Neurosci 2022; 15:767489. [PMID: 35069132 PMCID: PMC8776628 DOI: 10.3389/fnsys.2021.767489] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/13/2021] [Indexed: 12/05/2022] Open
Abstract
In the last decade, burst suppression has been increasingly studied by many to examine whether it is a mechanism leading to postoperative cognitive impairment. Despite a lack of consensus across trials, the current state of research suggests that electroencephalogram (EEG) burst suppression, duration and EEG emergence trajectory may predict postoperative delirium (POD). A mini literature review regarding evidence about burst suppression impact and susceptibilities was conducted, resulting in conflicting studies. Primarily, studies have used different algorithm values to replace visual burst suppression examination, although many studies have since emerged showing that algorithms underestimate burst suppression duration. As these methods may not be interchangeable with visual analysis of raw data, it is a potential factor for the current heterogeneity between data. Even though additional research trials incorporating the use of raw EEG data are necessary, the data currently show that monitoring with commercial intraoperative EEG machines that use EEG indices to estimate burst suppression may help physicians identify burst suppression and guide anesthetic titration during surgery. These modifications in anesthetics could lead to preventing unfavorable outcomes. Furthermore, some studies suggest that brain age, baseline impairment, and certain medications are risk factors for burst suppression and postoperative delirium. These patient characteristics, in conjunction with intraoperative EEG monitoring, could be used for individualized patient care. Future studies on the feasibility of raw EEG monitoring, new technologies for anesthetic monitoring and titration, and patient-associated risk factors are crucial to our continued understanding of burst suppression and postoperative delirium.
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