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Efforts to conceptualize risk factors for postoperative delirium in older adults have focused on the time proximate to the episode, but how early-life exposures influence delirium risk is poorly understood. An observational cohort of 547 patients aged 70+undergoing major non-cardiac surgery at two academic medical centers in Boston. Demographic characteristics, cognition, parental education, health, and participation in cognitively stimulating activities were assessed prior to surgery. Delirium incidence and severity were measured daily during hospitalization. Higher paternal education was associated with significantly lower incidence of delirium (X2(1, N =547)=8.35, p <.001; odds ratio OR=.93, 95% CI,.87 to.98) and inversely associated with delirium severity (r(545)=−.13, p <.001). Higher maternal education was associated with lower delirium incidence but did not reach statistical significance. The effect of paternal education on delirium incidence was independent of the patient's education, estimated premorbid intelligence, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities (X2(2, N =547)=31.22, p <.001). Examining early-life exposures may yield unique insights into the risks and pathogenesis of delirium. Evaluating long-term factors that increase vulnerability to delirium may improve our ability to calculate risk. It may guide clinical decision-making and inform pre- and post-operative recommendations. [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]