Background: Recent limited evidence suggests that the use of processed electroencephalographic (EEG) monitor to guide anesthetic management may influence postoperative cognitive outcomes, however, the mechanism is unclear.Methods: This exploratory single center, randomized clinical trial included patients who were ≥ 65 years of age undergoing elective non-cardiac surgery. The study aimed to determine whether monitoring the brain using a processed EEG monitor reduced EEG suppression and subsequent postoperative delirium. The interventional group received processed EEG-guided anesthetic management to keep the Patient State Index (PSI) above 35 computed by the SEDline Brain Function Monitor while the standard care group was also monitored but the EEG data were blinded from the clinicians. The primary outcome was intraoperative EEG suppression. A secondary outcome was incident postoperative delirium during the first three days after surgery.Results: All outcomes were analyzed using the intention-to-treat paradigm. 204 patients with a mean age of 72 ± 5 years were studied. Minutes of EEG suppression adjusted by the length of surgery was found to be less for the interventional group than the standard care group (median, interquartile range 1.4% (5.0%) and 2.5% (10.4%); Hodges-Lehmann estimated median difference (95% CI) of −0.8% (−2.1%, −0.000009%). The effect of the intervention on EEG suppression differed for those with and without preoperative cognitive impairment (interaction P=0.01), with
Objective to determine whether incident postoperative delirium in elective older surgical patient was associated with increased risk for mortality, controlling for covariates of 5-year mortality. Design secondary analysis of prospective cohort studies. Setting academic Medical Center. Subjects patients ≥65 years of age undergoing elective non-cardiac surgery. Outcomes postoperative assessments of delirium measured using the Confusion Assessment Method (CAM), mortality within 5 years of the index surgery was determined from National Death Index records. Results postoperative delirium occurred in 332/1,315 patients (25%). Five years after surgery, 175 patients (13.3%) were deceased. Older age was associated with an increased odds of mortality [odds ratio (OR) 1.90, 95% confidence interval (CI) 1.20–2.70] for those aged 70–79 years compared to those aged <70 years, and OR 3.29, 95% CI 2.14–5.06 for those aged >80 years. Other variables associated with 5-year mortality on bi-variate analyses were white race, self-rated functional status, lower preoperative cognitive status, higher risk score as measured by the American Society of Anesthesiologists (ASA) classification, higher surgical risk score, history of congestive heart failure, myocardial infarction, renal disease, cancer, peripheral vascular disease and postoperative delirium. However, postoperative delirium was not associated with 5-year mortality on multi-variate logistic regression (OR 1.18, 95% CI 0.85–1.65). Conclusions our results showed that delirium was not associated with 5-year mortality in elective surgical patients after consideration of co-variates of mortality. Our results suggest the importance of accounting for known preoperative risks for mortality when investigating the relationship between delirium and long-term mortality.
Despite the association between cognitive impairment and delirium, little is known about whether genetic differences that confer cognitive resilience also confer resistance to delirium. To investigate whether older adults without postoperative delirium, compared with those with postoperative delirium, are more likely to have specific single nucleotide polymorphisms (SNPs) in the FKBP5, KIBRA, KLOTHO, MTNR1B, and SIRT1 genes known to be associated with cognition or delirium. This prospective nested matched exploratory case–control study included 94 older adults who underwent orthopedic surgery and screened for postoperative delirium. Forty-seven subjects had incident delirium, and 47 age-matched controls were not delirious. The primary study outcome was genotype frequency for the five SNPs. Compared with participants with delirium, those without delirium had higher adjusted odds of KIBRA SNP rs17070145 CT/TT [vs. CC; adjusted odds ratio (aOR) 2.80, 95% confidence interval (CI) 1.03, 7.54; p = 0.04] and MTNR1B SNP rs10830963 CG/GG (vs. CC; aOR 4.14, 95% CI 1.36, 12.59; p = 0.01). FKBP5 SNP rs1360780 CT/TT (vs. CC) demonstrated borderline increased adjusted odds of not developing delirium (aOR 2.51, 95% CI 1.00, 7.34; p = 0.05). Our results highlight the relevance of KIBRA, MTNR1B, and FKBP5 in understanding the complex relationship between delirium, cognition, and sleep, which warrant further study in larger, more diverse populations.
Objectives/Background: Sleep disruption is prevalent in older patients. No previous studies have considered the impact of surgery duration or surgery end time of day on postoperative sleep disruption. Accordingly, we examined the duration of surgery and surgery end times for associations with postoperative sleep disruption.Methods: Inclusion criteria were patients ≥ 65 years of age undergoing major, non-cardiac surgery. Sleep disruption was measured by wrist actigraphy and defined as wake after sleep onset (WASO) during the night, or inactivity/sleep time during the day. The sleep opportunity window was set from 22:00 to 06:00 which coincided with "lights off and on" in the hospital. WASO during this 8-hour period on the first postoperative day was categorized into one of three groups: ≤ 15%, 15-25%, and > 25%. Daytime sleep (inactivity) during the first postoperative day was categorized as ≤ 20%, 20-40%, and > 40%. Statistical analyses were conducted to test for associations between surgery duration, surgery end time and sleep disruption on the first postoperative day and following night.Results: For this sample of 156 patients, surgery duration ≥ 6 hours and surgery end time after 19:00 were not associated with WASO groups (p = 0.17, p = 0.94, respectively). Furthermore, daytime sleep was also not affected by surgery duration or surgery end time (p = 0.07, p = 0.06 respectively). Conclusion:Our hypothesis that patients with longer duration or later-ending operations have increased postoperative sleep disruption was not supported. Our results suggest the pathophysiology of postoperative sleep disruption needs further investigation.
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