Search

Background: Examining the associations of social determinants of health (SDOH) with postoperative delirium in older adults will broaden our understanding of this potentially devastating condition. We explored the association between SDOH factors and incident postoperative delirium. Methods: A retrospective study of a prospective cohort of patients enrolled from June 18, 2010, to August 8, 2013, across two academic medical centers in Boston, Massachusetts. Overall, 560 older adults age ≥70 years undergoing major elective non‐cardiac surgery were included in this analysis. Exposure variables included income, lack of private insurance, and neighborhood disadvantage. Our main outcome was incident postoperative delirium, measured using the Confusion Assessment Method long form. Results: Older age (odds ratio, OR: 1.01, 95% confidence interval, CI: 1.00, 1.02), income <20,000 a year (OR: 1.12, 95% CI: 1.00, 1.26), lack of private insurance (OR: 1.19, 95% CI: 1.04, 1.38), higher depressive symptomatology (OR: 1.02, 95% CI: 1.01, 1.04), and the Area Deprivation Index (OR: 1.02, 95% CI: 1.01, 1.04) were significantly associated with increased risk of postoperative delirium in bivariable analyses. In a multivariable model, explaining 27% of the variance in postoperative delirium, significant independent variables were older age (OR 1.01, 95% CI 1.00, 1.02), lack of private insurance (OR 1.18, 95% CI 1.02, 1.36), and depressive symptoms (OR 1.02, 95% CI 1.00, 1.03). Household income was no longer a significant independent predictor of delirium in the multivariable model (OR:1.02, 95% CI: 0.90, 1.15). The type of medical insurance significantly mediated the association between household income and incident delirium. Conclusions: Lack of private insurance, a social determinant of health reflecting socioeconomic status, emerged as a novel and important independent risk factor for delirium. Future efforts should consider targeting SDOH factors to prevent postoperative delirium in older adults. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the extent to which preoperative performance on tests of executive function and memory was associated with delirium after coronary artery bypass graft (CABG) surgery. DESIGN: Prospective observational cohort study. SETTING: Two academic medical centers and one Department of Veterans Affairs medical center in Massachusetts. PARTICIPANTS: Eighty subjects without preoperative delirium undergoing CABG or CABG-valve surgery completed baseline neuropsychological assessments with validated measures of memory and executive function. MEASUREMENTS: Beginning on postoperative Day 2, a battery to diagnose delirium was administered daily. Confirmatory factor analysis (CFA) was used to define two cognitive domain composites (memory and executive function). The loading pattern of neuropsychological measures onto the latent cognitive domains was determined a priori. Poisson regression was used to model the association between neuropsychological performance and cognitive domain composite scores and risk of postoperative delirium. The association was expressed as the difference between impaired (0.5 standard deviations (SDs) below mean) and nonimpaired (0.5 SDs above mean) performers. RESULTS: Forty subjects (50%) developed delirium. Measures of memory function were not significantly related to delirium. Of the executive function measures, verbal fluency, category fluency, Hopkins Verbal Learning Test learning, and backward recounting of days and months were significantly related to delirium. Preoperative mental status was a strong predictor of postoperative delirium. After controlling for age, sex, education, medical comorbidity, mental status, and the other cognitive domain, CFA cognitive domain composites suggest that risk for delirium is specific for executive functioning impairment (relative risk (RR) = 2.77, 95% confidence interval (CI) = 1.12–6.87) but not for memory impairment (RR = 0.49, 95% CI = 0.19–1.25). CONCLUSION: Worse preoperative performance in executive function was independently associated with greater risk of developing delirium after CABG. [ABSTRACT FROM AUTHOR]

BACKGROUND/OBJECTIVES: Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between neighborhood‐level characteristics and delirium incidence and severity, and compared neighborhood‐ with individual‐level indicators of socioeconomic status in predicting delirium incidence. DESIGN: A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status. SETTING: Two academic medical centers in Boston, MA. PARTICIPANTS: A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery. INTERVENTION: The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage. MEASUREMENTS: Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM‐S) occurring during daily hospital assessments (CAM‐S Peak). RESULTS: Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3–3.1). The CAM‐S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P =.009). Mean CAM‐S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual‐level markers of socioeconomic status and cultural background were: 1.2 (0.9–1.7) for education of 12 years or less; 1.3 (0.8–2.1) for non‐White race; and 1.7 (1.1–2.6) for annual household income of less than $20,000. None of these individual‐level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk. CONCLUSIONS: Neighborhood‐level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure‐response relationship. Future studies should consider contextual‐level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention. [ABSTRACT FROM AUTHOR]

Objectives To examine the effect of hospital readmission on functional recovery after elective surgery in older adults. Design Prospective cohort of individuals aged 70 and older undergoing elective surgery, enrolled from June 2010 to August 2013. Setting Two academic medical centers. Participants Community-dwelling older adults (N = 566; mean age ± standard deviation 77 ± 5) undergoing major elective surgery and expected to be admitted for at least 3 days. Measurements Readmission was assessed in multiple interviews with participants and family members over 18 months and validated against medical record review. Physical function was assessed according to ability to perform instrumental activities of daily living ( IADLs) and activities of daily living ( ADL), Medical Outcomes Study 12-item Short-Form Survey Physical Component Summary score, and a standardized functional composite. Results Two hundred fifty-five (45%) participants experienced 503 readmissions. Readmissions were associated with delays in functional recovery in all measures of physical function. Having two or more readmissions over 18 months was associated with persistent and significantly greater risk of IADL dependence (relative risk ( RR) = 1.8, 95% confidence interval ( CI) = 1.5-2.3) and ADL dependence ( RR = 3.3, 95% CI = 1.7-6.4). Degree of functional impairment increased progressively with number of readmissions. Readmissions within 2 months resulted in delayed functional recovery to baseline by 18 months, and readmissions between 12 and 18 months after surgery resulted in loss of functional recovery previously achieved. Conclusion Readmission after elective surgery may contribute to delays in functional recovery and persistent functional deficits in older adults. [ABSTRACT FROM AUTHOR]

Objectives To apply the Frailty Phenotype ( FP) and Frailty Index ( FI) before major elective orthopedic surgery to categorize frailty status and assess associations with postoperative outcomes. Design Prospective cohort study. Setting Two tertiary hospitals in Boston, Massachusetts. Participants Individuals aged 70 and older undergoing scheduled orthopedic surgery enrolled in the Successful Aging after Elective Surgery ( SAGES) Study (N = 415). Measurements Preoperative evaluation included assessment of frailty using the FP and FI. The weighted kappa statistic was used to determine concordance between the two frailty measures and multivariable modeling to determine associations between each measure and postoperative complications, postoperative length of stay ( LOS) of longer than 5 days, discharge to postacute institutional care ( PAC), and 300 day readmission. Results Frailty was highly prevalent ( FP, 35%; FI, 41%). There was moderate concordance between the FP and FI ( κ = 0.42, 95% confidence interval ( CI) 0.36-0.49). When using the FP, being prefrail predicted greater risk of complications (relative risk ( RR) = 1.6, 95% CI = 1.1-2.1) and discharge to PAC ( RR = 1.8, 95% CI = 1.2-2.9) than being robust, and being frail predicted more complications ( RR = 1.7, 95% CI = 1.1-2.1), LOS longer than 5 days ( RR = 3.1, 95% CI = 1.1-8.8), and discharge to PAC ( RR = 2.3 95% CI = 1.4-3.7). When using FI, being prefrail predicted LOS longer than 5 days ( RR = 2.1, 95% CI = 1.0-4.8) and discharge to PAC ( RR = 1.5, 95% CI = 1.4-2.1), as did being frail ( RR = 1.9, 95% CI = 1.4-2.5; RR = 3.1, 95% CI = 1.4-6.8, respectively). The other outcomes were not significantly associated with frailty status. Conclusion FP and FI predict postoperative outcomes after major elective orthopedic surgery and should be considered for preoperative risk stratification. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To establish Montreal Cognitive Assessment (MoCA) scores that correspond to well-established cut-points on the Mini-Mental State Examination (MMSE). DESIGN: Cross-sectional observational study. SETTING: General medical service of a large teaching hospital. PARTICIPANTS: Individuals aged 75 and older (N = 199; mean age 84, 63% female). MEASUREMENTS: The MoCA (range 0-30) and the MMSE (range 0-30) were administered within 2 hours of each other. The Abbreviated MoCA (A-MoCA; range 0-22) was calculated from the full MoCA. Scores from the three tests were analyzed using equipercentile equating, a statistical method for determining comparable scores on different tests of a similar construct by estimating per-centile equivalents. RESULTS: MoCA scores were lower (mean 19.3 ± 5.8) than MMSE scores (mean 24.1 ± 6.6). Traditional MMSE cut-points of 27 for mild cognitive impairment and 23 for dementia corresponded to MoCA scores of 23 and 17, respectively. CONCLUSION: Scores on the full and abbreviated versions of the MoCA can be linked directly to the MMSE. The MoCA may be more sensitive to changes in cognitive performance at higher levels of functioning. [ABSTRACT FROM AUTHOR]

Objectives To examine baseline (preoperative) neuropsychological test performance in a cohort of elderly individuals undergoing elective surgery and the association between specific neuropsychological domains and postoperative delirium. Design Ongoing prospective cohort study. Setting Successful Aging after Elective Surgery Study. Participants Elderly adults (N = 300) scheduled for elective (noncardiac) surgery. Measurements Neuropsychological testing, including standardized assessments of memory, divided and sustained attention, speed of mental processing, verbal fluency, working memory, language, and an overall measure of premorbid cognitive functioning, was performed 2 to 4 weeks before surgery. The relationship between the individual neuropsychological tests and delirium status was examined using linear regression, adjusting for age, sex, and education. Results Study participants were generally highly educated (mean years of education 15.0 ± 2.9), with minimal or no cognitive impairment (mean Modified Mini-Mental State Examination score 93.2 out of 100). After adjustment, participants who developed postoperative delirium had performed significantly lower preoperatively on measures of speed of mental processing and divided attention (Trail-Making Test Part B, mean difference 17.55, P = .02), category fluency (animal naming, mean difference −1.94, P = .01), sustained visual attention (Visual Search and Attention, mean difference −3.19, P < .001), and working memory with new learning and recall (Hopkins Verbal Learning Test-Revised Total mean difference −0.53 to −0.79, P < .01). Conclusion Individuals who later develop delirium have lower scores on tests evaluating the areas of complex attention, executive functioning, and rapid access to verbal knowledge or semantic networks at baseline. Future studies to better understand how the cognitive profiles identified may predispose individuals to developing delirium may help pave the way to greater understanding of the mechanisms of delirium. [ABSTRACT FROM AUTHOR]