Search

Key Points: Question: Does electroencephalography-guided anesthetic administration to minimize electroencephalography suppression decrease the incidence of postoperative delirium in older patients undergoing cardiac surgery? Findings: In this multicenter randomized clinical trial involving 1140 patients aged 60 years and older undergoing cardiac surgery, postoperative delirium occurred in 18.15% of participants in the electroencephalography-guided anesthetic group and 18.10% in the usual care group, a difference that was not statistically significant. Meaning: These findings do not support the use of electroencephalography-guided anesthetic administration for the prevention of postoperative delirium among older adults undergoing cardiac surgery. Importance: Intraoperative electroencephalogram (EEG) waveform suppression, suggesting excessive general anesthesia, has been associated with postoperative delirium. Objective: To assess whether EEG-guided anesthesia decreases the incidence of delirium after cardiac surgery. Design, Setting, and Participants: Randomized, parallel-group clinical trial of 1140 adults 60 years or older undergoing cardiac surgery at 4 Canadian hospitals. Recruitment was from December 2016 to February 2022, with follow-up until February 2023. Interventions: Patients were randomized in a 1:1 ratio (stratified by hospital) to receive EEG-guided anesthesia (n = 567) or usual care (n = 573). Patients and those assessing outcomes were blinded to group assignment. Main Outcomes and Measures: The primary outcome was delirium during postoperative days 1 through 5. Intraoperative measures included anesthetic concentration and EEG suppression time. Secondary outcomes included intensive care and hospital length of stay. Serious adverse events included intraoperative awareness, medical complications, and 30-day mortality. Results: Of 1140 randomized patients (median [IQR] age, 70 [65-75] years; 282 [24.7%] women), 1131 (99.2%) were assessed for the primary outcome. Delirium during postoperative days 1 to 5 occurred in 102 of 562 patients (18.15%) in the EEG-guided group and 103 of 569 patients (18.10%) in the usual care group (difference, 0.05% [95% CI, −4.57% to 4.67%]). In the EEG-guided group compared with the usual care group, the median volatile anesthetic minimum alveolar concentration was 0.14 (95% CI, 0.15 to 0.13) lower (0.66 vs 0.80) and there was a 7.7-minute (95% CI, 10.6 to 4.7) decrease in the median total time spent with EEG suppression (4.0 vs 11.7 min). There were no significant differences between groups in median length of intensive care unit (difference, 0 days [95% CI, −0.31 to 0.31]) or hospital stay (difference, 0 days [95% CI, −0.94 to 0.94]). No patients reported intraoperative awareness. Medical complications occurred in 64 of 567 patients (11.3%) in the EEG-guided group and 73 of 573 (12.7%) in the usual care group. Thirty-day mortality occurred in 8 of 567 patients (1.4%) in the EEG-guided group and 13 of 573 (2.3%) in the usual care group. Conclusions and Relevance: Among older adults undergoing cardiac surgery, EEG-guided anesthetic administration to minimize EEG suppression, compared with usual care, did not decrease the incidence of postoperative delirium. This finding does not support EEG-guided anesthesia for this indication. Trial Registration: ClinicalTrials.gov Identifier: NCT02692300 This randomized clinical trial examines whether electroencephalogram -guided anesthesia decreases the incidence of delirium after cardiac surgery among adults 60 years or older. [ABSTRACT FROM AUTHOR]

Background: Recent studies have reported an association between presurgical frailty and postoperative delirium. However, it remains unclear whether the frailty‐delirium relationship differs by measurement tool (e.g., frailty index vs. frailty phenotype) and whether frailty is associated with delirium, independent of preoperative cognition. Methods: We used the successful aging after elective surgery (SAGES) study, a prospective cohort of older adults age ≥70 undergoing major non‐cardiac surgery (N = 505). Preoperative measurement of the modified mini‐mental (3MS) test, frailty index and frailty phenotype were obtained. The confusion assessment method (CAM), supplemented by chart review, identified postoperative delirium. Delirium feature severity was measured by the sum of CAM‐severity (CAM‐S) scores. Generalized linear models were used to determine the relative risk of each frailty measure with delirium incidence and severity. Subsequent models adjusted for age, sex, surgery type, Charlson comorbidity index, and 3MS. Results: On average, patients were 76.7 years old (standard deviation 5.22), 58.8% of women. For the frailty index, the incidence of delirium was 14% in robust, 17% in prefrail, and 31% in frail patients (p < 0.001). For the frailty phenotype, delirium incidence was 13% in robust, 21% in prefrail, and 27% in frail patients (p = 0.016). Frailty index, but not phenotype, was independently associated with delirium after adjustment for comorbidities (relative risk [RR] 2.13, 95% confidence interval [CI] 1.23–3.70; RR 1.61, 95% CI 0.77–3.37, respectively). Both frailty measures were associated with delirium feature severity. After adjustment for preoperative cognition, only the frailty index was associated with delirium incidence; neither index nor phenotype was associated with delirium feature severity. Conclusion: Both the frailty index and phenotype were associated with the development of postoperative delirium. The index showed stronger associations that remained significant after adjusting for baseline comorbidities and preoperative cognition. Measuring frailty prior to surgery can assist in identifying patients at risk for postoperative delirium. See related Editorial by Callahan and Kuchel in this issue. [ABSTRACT FROM AUTHOR]

Objective: To develop an individualized method for detecting cognitive adverse events (CAEs) in the context of an ongoing trial of electroconvulsive therapy for refractory agitation and aggression for advanced dementia (ECT-AD study). Methods: Literature search aimed at identifying (a) cognitive measures appropriate for patients with advanced dementia, (b) functional scales to use as a proxy for cognitive status in patients with floor effects on baseline cognitive testing, and (c) statistical approaches for defining a CAE, to develop CAEs monitoring plan specifically for the ECT-AD study. Results: Using the Severe Impairment Battery-8 (SIB-8), baseline floor effects are defined as a score of ≤5/16. For patients without floor effects, a decline of ≥6 points is considered a CAE. For patients with floor effects, a decline of ≥30 points from baseline on the Barthel Index is considered a CAE. These values were derived using the standard deviation index (SDI) approach to measuring reliable change. Conclusions: The proposed plan accounts for practical and statistical challenges in detecting CAEs in patients with advanced dementia. While this protocol was developed in the context of the ECT-AD study, the general approach can potentially be applied to other interventional neuropsychiatric studies that carry the risk of CAEs in patients with advanced dementia. [ABSTRACT FROM AUTHOR]

Solidarity experienced a revival during the COVID-19 pandemic and has been an important component of the political discourse in every economic—and therefore also the social—crisis that hit Europe in the last years. This contribution aims to assess the relevance that members of German governing parties at the Laender level attached to solidarity during the COVID-19 pandemic. By conducting a frame analysis, we identify calls to different types of solidarity, and brought these in relation to the explanatory power of situational aspects, economic interests and party-political positions. Empirical analysis displays that solidarity is an important, albeit not too frequently used frame, in crisis dialogue. High threat perception (but not actual threat) appears to foster claims to solidarity and other forms of communal behaviour, while the economic situation and party-political stances do not exhibit an equally strong effect. Nevertheless, aligned party-political positions on solidarity go along with a reduced understanding of the concept, which primarily serves as a justification for placing a burden on the caretakers of society. This traditional notion of solidarity is even more prominent amongst leftist party members, a fact raising questions concerning the distinctiveness of German party positions, as well as concerning social equality. [ABSTRACT FROM AUTHOR]

Background: The Successful Aging after Elective Surgery (SAGES) II Study was designed to examine the relationship between delirium and Alzheimer's disease and related dementias (AD/ADRD), by capturing novel fluid biomarkers, neuroimaging markers, and neurophysiological measurements. The goal of this paper is to provide the first complete description of the enrolled cohort, which details the baseline characteristics and data completion. We also describe the study modifications necessitated by the COVID‐19 pandemic, and lay the foundation for future work using this cohort. Methods: SAGES II is a prospective observational cohort study of community‐dwelling adults age 65 and older undergoing major non‐cardiac surgery. Participants were assessed preoperatively, throughout hospitalization, and at 1, 2, 6, 12, and 18 months following discharge to assess cognitive and physical functioning. Since participants were enrolled throughout the COVID‐19 pandemic, procedural modifications were designed to reduce missing data and allow for high data quality. Results: About 420 participants were enrolled with a mean (standard deviation) age of 73.4 (5.6) years, including 14% minority participants. Eighty‐eight percent of participants had either total knee or hip replacements; the most common surgery was total knee replacement with 210 participants (50%). Despite the challenges posed by the COVID‐19 pandemic, which required the use of novel procedures such as video assessments, there were minimal missing interviews during hospitalization and up to 1‐month follow‐up; nearly 90% of enrolled participants completed interviews through 6‐month follow‐up. Conclusion: While there are many longitudinal studies of older adults, this study is unique in measuring health outcomes following surgery, along with risk factors for delirium through the application of novel biomarkers—including fluid (plasma and cerebrospinal fluid), imaging, and electrophysiological markers. This paper is the first to describe the characteristics of this unique cohort and the data collected, enabling future work using this novel and important resource. [ABSTRACT FROM AUTHOR]

Objectives: Determine if biomarkers of Alzheimer's disease and neural injury may play a role in the prediction of delirium risk. Methods: In a cohort of older adults who underwent elective surgery, delirium case‐no delirium control pairs (N = 70, or 35 matched pairs) were matched by age, sex and vascular comorbidities. Biomarkers from CSF and plasma samples collected prior to surgery, including amyloid beta (Aβ)42, Aβ40, total (t)‐Tau, phosphorylated (p)‐Tau181, neurofilament‐light (NfL), and glial fibrillary acid protein (GFAP) were measured in cerebrospinal fluid (CSF) and plasma using sandwich enzyme‐linked immunosorbent assays (ELISAs) or ultrasensitive single molecule array (Simoa) immunoassays. Results: Plasma GFAP correlated significantly with CSF GFAP and both plasma and CSF GFAP values were nearly two‐fold higher in delirium cases. The median paired difference between delirium case and control without delirium for plasma GFAP was not significant (p = 0.074) but higher levels were associated with a greater risk for delirium (odds ratio 1.52, 95% confidence interval 0.85, 2.72 per standard deviation increase in plasma GFAP concentration) in this small study. No matched pair differences or associations with delirium were observed for NfL, p‐Tau 181, Aβ40 and Aβ42. Conclusions: These preliminary findings suggest that plasma GFAP, a marker of astroglial activation, may be worth further investigation as a predictive risk marker for delirium. Key points: Delirium is a common complication of hospitalization associated with poor outcomes, but the underlying pathophsysiology of this condition is poorly understoodThere is a close interrelationship between delirium and dementia, therefore CSF and blood biomarkers for Alzheimer's Disease and neural injury might be associated with deliriumWe found that plasma and CSF glial fibrillary acid protein (GFAP), a marker of reactive gliosis known to be elevated in neurodegeneration, appears to be related to delirium risk, with a nearly two‐fold greater odds of deliriumFurther larger studies are needed to understand the potential role of GFAP as a predictive risk marker for delirium [ABSTRACT FROM AUTHOR]

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]

Purpose: The purpose of this study was to assess the association between Adult Day Health Center (ADHC) participation and health-related quality of life. Design and Methods: Case-controlled prospective study utilizing the Medical Outcomes Survey Form 36 (SF-36) to compare newly enrolled participants from 16 ADHC programs with comparable community-dwelling older adults who did not attend an ADHC. Assessments were conducted at study enrollment, 6 and 12 months. Results: ADHC participants (n = 57) and comparison group subjects (n = 67) were similar at baseline in age, ethnic diversity, medical conditions, depression, cognition, immigration history, education, income, and marital status. Significantly more comparison group subjects lived alone (p = 0.002). One year after enrollment, the SF-36 domains role physical and role emotional improved significantly. Adjusted role physical scores for ADHC participants improved (23 vs. 36) but declined for the comparison group (38 vs. 26, time by group interaction p = 0.01), and role emotional scores improved for ADHC participants (62 vs.70) but declined for the comparison group (65 vs. 48, time by group interaction p = 0.02). Secondary analyses revealed that changes in daily physical functioning, depressed affect, or cognitive functioning did not explain the improvements found in role physical and role emotional scores for ADHC participants. No significant differences in trends for the 2 groups occurred for the SF-36 domains physical functioning, social functioning, and mental health. Implications: ADHC participation may enhance older adults' quality of life. Quality of life may be a key measure to inform care planning, program improvement, and policy development of ADHC.

Teaching in higher education increasingly requires greater accountability, the utilization of contemporary learner-focused teaching models, and transparent grading methods for nonstandardized learning products. This article describes learner-centered evaluation and assessment strategies and illustrates how these approaches emphasize learners' responsibility for their own learning, foster students' commitment to learning and provide useful information for continuous curriculum improvement. In addition, the article discusses the components of learner-centered assessment models including the course assessment and enhancement model, the Personal Action Plan, and the Gedanken Experiment. Further, a rubric is presented as a tool for systematic and transparent grading of learner-centered assessment products. The need for further validation of these strategies is being discussed. (Contains 2 tables and 1 figure.)

Background: The Successful Aging after Elective Surgery (SAGES) II study was designed to increase knowledge of the pathophysiology and linkages between delirium and dementia. We examine novel biomarkers potentially associated with delirium, including inflammation, Alzheimer's disease (AD) pathology and neurodegeneration, neuroimaging markers, and neurophysiologic markers. The goal of this paper is to describe the study design and methods for the SAGES II study. Methods: The SAGES II study is a 5‐year prospective observational study of 400–420 community dwelling persons, aged 65 years and older, assessed prior to scheduled surgery and followed daily throughout hospitalization to observe for development of delirium and other clinical outcomes. Delirium is measured with the Confusion Assessment Method (CAM), long form, after cognitive testing. Cognitive function is measured with a detailed neuropsychologic test battery, summarized as a weighted composite, the General Cognitive Performance (GCP) score. Other key measures include magnetic resonance imaging (MRI), transcranial magnetic stimulation (TMS)/electroencephalography (EEG), and Amyloid positron emission tomography (PET) imaging. We describe the eligibility criteria, enrollment flow, timing of assessments, and variables collected at baseline and during repeated assessments at 1, 2, 6, 12, and 18 months. Results: This study describes the hospital and surgery‐related variables, delirium, long‐term cognitive decline, clinical outcomes, and novel biomarkers. In inter‐rater reliability assessments, the CAM ratings (weighted kappa = 0.91, 95% confidence interval, CI = 0.74–1.0) in 50 paired assessments and GCP ratings (weighted kappa = 0.99, 95% CI 0.94–1.0) in 25 paired assessments. We describe procedures for data quality assurance and Covid‐19 adaptations. Conclusions: This complex study presents an innovative effort to advance our understanding of the inter‐relationship between delirium and dementia via novel biomarkers, collected in the context of major surgery in older adults. Strengths include the integration of MRI, TMS/EEG, PET modalities, and high‐quality longitudinal data. [ABSTRACT FROM AUTHOR]

Background: Post‐surgical delirium is associated with increased morbidity, lasting cognitive decline, and loss of functional independence. Within a conceptual framework that delirium is triggered by stressors when vulnerabilities exist in cerebral connectivity and plasticity, we previously suggested that neurophysiologic measures might identify individuals at risk for post‐surgical delirium. Here we demonstrate the feasibility of the approach and provide preliminary experimental evidence of the predictive value of such neurophysiologic measures for the risk of delirium in older persons undergoing elective surgery. Methods: Electroencephalography (EEG) and transcranial magnetic stimulation (TMS) were collected from 23 patients prior to elective surgery. Resting‐state EEG spectral power ratio (SPR) served as a measure of integrity of neural circuits. TMS–EEG metrics of plasticity (TMS‐plasticity) were used as indicators of brain capacity to respond to stressors. Presence or absence of delirium was assessed using the confusion assessment method (CAM). We included individuals with no baseline clinically relevant cognitive impairment (MoCA scores ≥21) in order to focus on subclinical neurophysiological measures. Results: In patients with no baseline cognitive impairment (N = 20, age = 72 ± 6), 3 developed post‐surgical delirium (MoCA = 24 ± 2.6) and 17 did not (controls; MoCA = 25 ± 2.4). Patients who developed delirium had pre‐surgical resting‐state EEG power ratios outside the 95% confidence interval of controls, and 2/3 had TMS‐plasticity measures outside the 95% CI of controls. Conclusions: Consistent with our proposed conceptual framework, this pilot study suggests that non‐invasive and scalable neurophysiologic measures can identify individuals at risk of post‐operative delirium. Specifically, abnormalities in resting‐state EEG spectral power or TMS‐plasticity may indicate sub‐clinical risk for post‐surgery delirium. Extension and confirmation of these findings in a larger sample is needed to assess the clinical utility of the proposed neurophysiologic markers, and to identify specific connectivity and plasticity targets for therapeutic interventions that might minimize the risk of delirium. [ABSTRACT FROM AUTHOR]