Preoperative Cognitive Impairment As a Predictor of Postoperative Outcomes in a Collaborative Care Model

Abstract

OBJECTIVES:To compare postoperative outcomes of individuals with and without cognitive impairment enrolled in the Perioperative Optimization of Senior Health (POSH) program at Duke University, a comanagement model involving surgery, anesthesia, and geriatrics. DESIGN: Retrospective analysis of individuals enrolled in a quality improvement program. SETTING: Tertiary academic center. PARTICIPANTS: Older adults undergoing surgery and referred to POSH (N = 157). MEASUREMENTS: Cognitive impairment was defined as a score less than 25 out of 30 (adjusted for education) on the St. Louis University Mental Status (SLUMS) Examination. Median length of stay (LOS), mean number of postoperative complications, rates of postoperative delirium (POD, %), 30-day readmissions (%), and discharge to home (%) were compared using bivariate analysis. RESULTS: Seventy percent of participants met criteria for cognitive impairment (mean SLUMS score 20.3 for those with cognitive impairment and 27.7 for those without). Participants with and without cognitive impairment did not significantly differ in demographic characteristics, number of medications (including anticholinergics and benzodiazepines), or burden of comorbidities. Participants with and without cognitive impairment had similar LOS (P = .99), cumulative number of complications (P = .70), and 30-day readmission (P = .20). POD was more common in those with cognitive impairment (31% vs 24%), but the difference was not significant (P = .34). Participants without cognitive impairment had higher rates of discharge to home (80.4% vs 65.1%, P = .05). CONCLUSION: Older adults with and without cognitive impairment referred to the POSH program fared similarly on most postoperative outcomes. Individuals with cognitive impairment may benefit from perioperative geriatric comanagement. Questions remain regarding the validity of available measures of cognition in the preoperative period. J Am Geriatr Soc 2018.

Beyond Cognitive Screening: Establishing an Interprofessional Perioperative Brain Health Initiative

“…20 If complex older patients are to do well undergoing surgery, then cognitive screening, frailty assessment, and geriatric team involvement must become routine practice. 21,22 A limitation of this study is the exclusion of patients due to language barriers or inability to complete screening; the Mini-Cog is available in multiple languages, and we now plan to extend it to all patients. Another limitation is the relatively small sample size of the subset assessed without knowledge of Mini-Cog results; however, we felt this demonstrated the disconnect in provider ability to identify cognitive impairment without formal screening which is supported by other evidence, 12 and helped with buy-in for our initiative.…”

<p>Functional capacity as a predictor of postoperative delirium in transurethral resection of prostate patients in Northeast Brazil</p>

“…Regarding precipitating and predisposing factors for POD, age19,21,22 and preoperative use of benzodiazepines21 were factors associated with POD in elderly patients undergoing various types of low-complexity surgical procedures. The participants who received psychoactive drugs while in the hospital were more likely to have POD, which was shown to be independent of preoperative cognitive impairment in another study of patients admitted for hip fracture surgery.23 However, there were other reports of no differences in demographic characteristics, number of medications used (including anticholinergics and benzodiazepines) and number of comorbidities as predictors of delirium.24 Moreover, a recent meta-analysis from the United Kingdom25 concluded that there is low-quality evidence associating POD with medication use in patients undergoing hip fracture surgery.…”

RESEARCHCognition and Capacity to Consent for Elective Surgery

“…[1][2][3] Most studies evaluating UTI in older emergency department (ED) patients relied on electronic medical record (EMR) documentation as the criterion standard for the presence of symptoms. [3][4][5][6][7][8] Our goal was to investigate the accuracy of chart abstraction versus direct ED patient interview for the presence of GU symptoms. We used patient self-report as the criterion standard.…”

“…Twenty percent of adults aged 65 years or older have mild cognitive impairment or dementia, and the prevalence may be higher in perioperative patients. [1][2][3][4] There is little literature on the epidemiology of preoperative incapacity, although diminished cognition correlates with impaired capacity for medical decision-making. [5][6][7] As the population ages, it is imperative to recognize and manage patients with incapacity to consent for their upcoming surgeries.…”