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Background Arousal and awareness are two important components of consciousness states. Functional neuroimaging has furthered our understanding of cortical and thalamocortical mechanisms of awareness. Investigating the relationship between subcortical functional connectivity and arousal has been challenging owing to the relatively small size of brainstem structures and thalamic nuclei, and their depth in the brain. Methods Resting state functional MRI scans of 72 healthy volunteers were acquired before, during, 1 h after, and 1 day after sevoflurane general anaesthesia. Functional connectivity of subcortical regions of interest vs whole brain and homotopic functional connectivity for assessment of left–right symmetry analyses of both cortical and subcortical regions of interest were performed. Both analyses used high resolution atlases generated from deep brain stimulation applications. Results Functional connectivity in subcortical loci within the thalamus and of the ascending reticular activating system was sharply restricted under anaesthesia, featuring a general lateralisation of connectivity. Similarly, left–right homology was sharply reduced under anaesthesia. Subcortical bilateral functional connectivity was not fully restored after emergence from anaesthesia, although greater restoration was seen between ascending reticular activating system loci and specific thalamic nuclei thought to be involved in promoting and maintaining arousal. Functional connectivity was fully restored to baseline by the following day. Conclusions Functional connectivity in the subcortex is sharply restricted and lateralised under general anaesthesia. This restriction may play a part in loss and return of consciousness. Clinical trial registration NCT02275026.

BACKGROUND Some older adults show exaggerated responses to drugs that act on the brain. The brain's response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG-based measure of the brain's resistance to volatile anesthetics and hypothesized that low scores on it would be associated with postoperative delirium risk. METHODS We defined the Duke Anesthesia Resistance Scale (DARS) as the average bispectral index (BIS) divided by the quantity (2.5 minus the average age-adjusted end-tidal minimum alveolar concentration [aaMAC] inhaled anesthetic fraction). The relationship between DARS and postoperative delirium was analyzed in 139 older surgical patients (age ≥65) from Duke University Medical Center (n = 69) and Mt Sinai Medical Center (n = 70). Delirium was assessed by geriatrician interview at Duke, and by research staff utilizing the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) instrument at Mt Sinai. We examined the relationship between DARS and delirium and used the Youden index to identify an optimal low DARS threshold (for delirium risk), and its associated 95% bootstrap confidence bounds. We used multivariable logistic regression to examine the relationship between low DARS and delirium risk. RESULTS The relationship between DARS and delirium risk was nonlinear, with higher delirium risk at low DARS scores. A DARS threshold of 28.755 maximized the Youden index for the association between low DARS and delirium, with bootstrap 95% confidence bounds of 26.18 and 29.80. A low DARS (

Background A growing body of literature addresses the possible long-term cognitive effects of anaesthetics, but no study has delineated the normal trajectory of neural recovery attributable to anaesthesia alone in adults. We obtained resting-state functional MRI scans on 72 healthy human volunteers between ages 40 and 80 (median: 59) yr before, during, and after general anaesthesia with sevoflurane, in the absence of surgery, as part of a larger study on cognitive function postanaesthesia. Methods Region-of-interest analysis, independent component analysis, and seed-to-voxel analysis were used to characterise resting-state functional connectivity and to differentiate between correlated and anticorrelated connectivity before, during, and after general anaesthesia. Results Whilst positively correlated functional connectivity remained essentially unchanged across these perianaesthetic states, anticorrelated functional connectivity decreased globally by 35% 1 h after emergence from general anaesthesia compared with baseline, as seen by the region-of-interest analysis. This decrease corresponded to a consistent reduction in expression of canonical resting-state networks, as seen by independent component analysis. All measures returned to baseline 1 day later. Conclusions The normal perianaesthesia trajectory of resting-state connectivity in healthy adults is characterised by a transient global reduction in anticorrelated activity shortly after emergence from anaesthesia that returns to baseline by the following day. Clinical trial registration NCT02275026.

BACKGROUND: Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery. METHODS: We performed a prospective cohort study of patients greater than 65 years-old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire which categorizes patients as robust, prefrail, or frail. Delirium was assessed with the confusion assessment method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Exam) prior to surgery and at 3 months afterwards. RESULTS: 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow up 3 months after surgery. The median age was 70 years old. 31 patients (18.6%) tested as frail, and 72 (43.1%) prefrail prior to surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiology (ASA) status, type of surgery, and gender, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval 1.0– 7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail or robust. CONCLUSIONS: After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL Scale is associated with increased odds of postoperative delirium, but not postoperative cognitive dysfunction after noncardiac surgery.

Older adults are the fastest growing segment of the population and surgical procedures in this group increase each year. Chronic post-surgical pain is an important consideration in the older adult as it affects recovery, physical functioning, and overall quality of life. It is increasingly recognized as a public health issue but there is a need to improve our understanding of the disease process as well as the appropriate treatment and prevention. Frailty, delirium, and cognition influence post-operative outcomes in older adults and have been implicated in the development of chronic post-surgical pain. Further research must be conducted to fully understand the role they play in the occurrence of chronic post-surgical pain in the older adult. Additionally, careful attention must be given to the physiologic, cognitive, and comorbidity differences between the older adult and the general population. This is critical for elucidating the proper chronic post-surgical pain treatment and prevention strategies to ensure that the older adult undergoing surgical intervention will have an appropriate and desirable post-operative outcome.

IntroductionDespite a clear association between cognitive impairment and physical frailty and poor postoperative outcomes in older adults, preoperative rates are rarely assessed. We sought to implement a preoperative cognitive impairment and frailty screening programme to meet the unique needs of our rural academic centre.MethodsThrough stakeholder interviews, we identified five primary drivers underlying screening implementation: staff education, technology infrastructure, workload impact, screening value and patient–provider communication. Based on these findings, we implemented cognitive dysfunction (AD8, Mini-Cog) and frailty (Clinical Frailty Scale) screening in our preoperative care clinic and select surgical clinics.ResultsIn the preoperative care clinic, many of our patients scored positive for clinical frailty (428 of 1231, 35%) and for cognitive impairment (264 of 1781, 14.8%). In our surgical clinics, 27% (35 of 131) and 9% (12 of 131) scored positive for clinical frailty and cognitive impairment, respectively. Compliance to screening improved from 48% to 86% 1 year later.ConclusionWe qualitatively analysed stakeholder feedback to drive the successful implementation of a preoperative cognitive impairment and frailty screening programme in our rural tertiary care centre. Preliminary data suggest that a clinically significant proportion of older adults screen positive for preoperative cognitive impairment and frailty and would benefit from tailored inpatient care.

Cognitive recovery after anaesthesia and surgery is a concern for older adults, their families, and caregivers. Reports of patients who were 'never the same' prompted a scientific inquiry into the nature of what patients have experienced. In June 2018, the ASA Brain Health Initiative held a summit to discuss the state of the science on perioperative cognition, and to create an implementation plan for patients and providers leveraging the current evidence. This group included representatives from the AARP (formerly the American Association of Retired Persons), American College of Surgeons, American Heart Association, and Alzheimer's Association Perioperative Cognition and Delirium Professional Interest Area. This paper summarises the state of the relevant clinical science, including risk factors, identification and diagnosis, prognosis, disparities, outcomes, and treatment of perioperative neurocognitive disorders. Finally, we discuss gaps in current knowledge with suggestions for future directions and opportunities for clinical and translational projects.

Despite increasing representation in medicine, women continue to be a minority in academic practice and leadership, especially in male-dominated fields like anesthesiology. Differences in compensation and participation in leadership may represent barriers to career advancement for women in anesthesiology. Key factors for promotion in academic anesthesiology are research, funding, and publication. As such, designation as a first or senior author on a publication in a professional journal may act as currency for promotion. Here, we examine the prevalence of female first and senior authorship of original research articles published in Anesthesiology and Anesthesia & Analgesia during the years 2002, 2007, 2012, and 2017. Other manuscript characteristics assessed in relation to author gender included study type, subspecialty topic, and total number of authors. Of 2600 manuscripts studied, analysis of authorship by year demonstrated an increase in female first authorship, senior authorship, and editorial board membership by 10%, 9%, and 6%, respectively. Women made up a higher percentage of first authors on manuscripts with female senior authors. More nonexperimental studies had female senior authors than experimental studies. Female first authors had greater representation in the subspecialties of neuroanesthesia, obstetrical anesthesia, pain management, and pediatric anesthesia. Median number of authors was unrelated to senior author gender. This study shows increasing female first and senior authorship, as well as editorial board composition in 2 popular, high-impact anesthesiology journals. Recognizing gender-based trends in publications is important to develop strategies for the recruitment, retention, and advancement of women in anesthesiology.

The goal of this study was to conduct a multi-domain, organ system-based analysis of non-surgical comorbidities amenable to pre-operative optimization in patients undergoing free tissue transfer, in order to better understand factors that influence patient outcomes.Retrospective review.Tertiary academic center.A retrospective analysis of 546 patients in a prospectively maintained database who underwent free tissue transfer reconstruction between 2007 and 2016 was performed. Analysis of the relationship between binary-coded system-based domains and log-transformed length of stay (LOS), rehabilitation requirement, 30-day readmission, and post-operative complications was conducted with multiple linear regression or logistic regression models.Poor nutritional status and the presence of anxiety/depression independently increased median hospital LOS. Endocrine and metabolic deficits, poor nutrition status, and psychiatric comorbidities were significant predictors for rehabilitation facility requirement upon discharge.Interventions targeted to patient psychiatric and nutritional health may yield substantially improved outcomes in the head and neck cancer population receiving free tissue transfer surgery.

Introduction: Studies addressing palliative care delivery in neuro-oncology are limited. Objectives: To compare inpatients with brain tumors who received palliative care (through referral or trigger) with those receiving usual care. Design: Retrospective cohort study. Setting/Subjects: Inpatients with primary or secondary brain tumors who did or did not receive palliative care at a U.S. medical center. Measurements: Sociodemographic, clinical, and utilization characteristics were compared. Results: Of 1669 brain tumor patients, 386 (23.1%) received palliative care [nontrigger: 246 (14.7%); trigger: 140 (8.4%)] and 1283 (76.9%) received usual care. Nontrigger patients were oldest (mean age 65.0 years; trigger: 61.1 years; usual care: 55.5 years; p

Postoperative cognitive dysfunction (POCD) is a decline in cognitive test performance which persists months after surgery. There has been great interest in the anesthesia community regarding whether variables generated by commercially available processed EEG monitors originally marketed to prevent awareness under anesthesia can be used to guide intraoperative anesthetic management to prevent POCD. Processed EEG monitors represent an opportunity for anesthesiologists to directly monitor the brain even if they have not been trained to interpret EEG waveforms. There is continued equipoise regarding whether any of the variables generated by the machines' interpretation of raw data are associated with POCD. Most literature has focused on the depth of anesthesia number, however recent studies have shown that processed depth may not be accurate in older age groups due to reduced alpha band power. Burst suppression is an encephalographic pattern of high voltage activity alternating with periods of electrical silence and is another marker of depth which can be obtained from commercial processed EEG monitors. We performed a prospective cohort study to determine whether burst suppression and burst suppression ratio as measured by the BIS Monitor (Bispectral Index, BIS Medtronic, Boulder CO), is associated with cognitive dysfunction 3 months after surgery. We recruited 167 elective surgery patients, 65 years of age and older, anticipated to require at least 2 day inpatient admission. Our main outcome measure was cognitive decline in composite z-score on the Alzheimer's Disease Research Center UDS Battery of at least 1 standard deviation 3 months after surgery relative to preoperative baseline. 14% experienced POCD, this group was older (72 [70, 74] versus 70 [67, 75] years), and had frailty scores as measured by the FRAIL Scale (2 [0, 3] versus 1 [0, 2]) and lower baseline z-scores (- 0.2 [- 0.6, 0.5] versus 0.1 [- 0.3, 0.5]). There was a univariable association between suppression ratio > 10 (SR > 10) and POCD (4.8 [0, 37.3] versus 15.4 [4.0-142.4] min), p = .038. However, after adjustment this relationship did not persist, only anesthetic technique, age, and pain remained in the model. In our cohort of older elective noncardiac surgery patients we found a marginal association between processed burst suppression (total burst suppression p = .067, SR > 5 p = .052, SR > 10.038) which did not persist in a multivariable model. Patients with POCD had almost twice the number of minutes of burst suppression, and three times the amount of time for SR > 5 and > 10. Our finding may be a limitation of the monitor's ability to detect burst suppression. The consistent trend towards more intraoperative burst suppression in patients who developed POCD suggests that future studies are needed to investigate the relationship of raw intraoperative burst suppression and POCD.Trial registry Clinical trial number and registry URL: Optimizing Postoperative Cognitive Dysfunction in the Elderly-PRESERVE, Clinical Trials Gov# NCT02650687; https://clinicaltrials.gov/ct2/show/NCT02650687 .

Objective In community dwelling older adults, depression and anxiety symptoms can be associated with early cognitive decline. Symptoms of depression and anxiety are common in older adults prior to surgery. However, their significance is unknown. Our objective was to determine whether preoperative depression and anxiety symptoms are associated with postoperative cognitive decline (POCD) and in‐hospital delirium, in older surgical patients. Methods We conducted a secondary data analysis of postoperative cognitive dysfunction in a cohort study of patients 65 and older undergoing elective noncardiac surgery. We used the Hospital Anxiety and Depression Scale (HADS) to screen for depression and anxiety symptoms at a home visit prior to surgery and 3 months after surgery. Patients with a history of psychiatric (major depressive disorder, bipolar disorder, and schizophrenia) or neurologic disorder (Parkinson's disease and stroke) were excluded from the parent study. Results Out of the 167 patients, 9.6% (n = 16) reported significant depressive symptoms and 21.6% (n = 36) reported significant anxiety symptoms on preoperative screening. There was no association between preoperative or new‐onset postoperative depression and anxiety symptoms and the incidence of delirium or POCD three months after surgery. Patients with preoperative depressive symptoms had higher preoperative pain (scores 69 vs. 35.7, p = .002) and frailty (56 vs. 14.6, p, Preoperative mood symptoms were related to physical pain and frailty. Taken together, these suggest that in patients without a formal psychiatric diagnosis, preoperative mood symptoms are related to physical state rather than a harbinger of early cognitive decline. Future studies are needed to understand the nature of the relationship between mood symptoms and physical state in surgical patients.

BackgroundSome older adults show exaggerated responses to drugs that act on the brain, such as increased delirium risk in response to anticholinergic drugs. The brain’s response to anesthetic drugs is often measured clinically by processed electroencephalogram (EEG) indices. Thus, we developed a processed EEG based-measure of the brain’s neurophysiologic resistance to anesthetic dose-related changes, and hypothesized that it would predict postoperative delirium.MethodsWe defined the Duke Anesthesia Resistance Scale (DARS) as the average BIS index divided by the quantity 2.5 minus the average age-adjusted end-tidal MAC (aaMAC) inhaled anesthetic fraction. The relationship between DARS and postoperative delirium was analyzed in derivation (Duke; N=69), validation (Mt Sinai; N=70), and combined estimation cohorts (N=139) of older surgical patients (age ≥65). In the derivation cohort, we identified a threshold relationship between DARS and for delirium and identified an optimal cut point for prediction.ResultsIn the derivation cohort, the optimal DARS threshold for predicting delirium was 27.0. The delirium rate was 11/49 (22.5%) vs 11/20 (55.0%) and 7/57 (12.3%) vs 6/13 (46.2%) for those with DARS ≥ 27 vs those with DARS < 27 in the derivation and validation cohorts respectively. In the combined estimation cohort, multivariable analysis found a significant association of DARS ConclusionsThese results suggest than an intraoperative processed EEG-based measure of lower brain anesthetic resistance (i.e. DARS

Intraoperative anesthetic technique directly impacts immediate postoperative recovery, yet there are few opportunities for anesthesiologists to receive feedback and no easily available benchmarks, making it difficult to reflect on one's own practice. This initial implementation study used retrospective data from 5,712 ambulatory surgery cases with healthy adult patients undergoing general anesthesia in 2018 at a large tertiary care academic center. It examines variation in practice among anesthesiologists for eight surgical specialties. Scorecards assessing intraoperative and postoperative opioids, antiemetics, nonopioid analgesics, regional blocks, recovery time, and severe postoperative pain compared with peers were given to anesthesiologists with prefeedback and postfeedback surveys assessing their attitudes toward feedback. Before receiving their scorecard, 71% of providers predicted their performance was average, and 29% predicted their performance was above average. After receiving their scorecards, 42% rated their quality of recovery as worse than expected, 42% rated it as expected, and 16% rated it as better than expected. Thirteen percent disagreed, 44% were neutral, and 44% agreed that this feedback will change their practice. Implementing a scorecard of patient-centered measures that shows where an anesthesiologist stands in the distribution of their peers was well-received, provides a benchmark, and has the potential to change practice.

Cognitive dysfunction after surgery under general anesthesia is a well-recognized clinical phenomenon in the elderly. Physiological effects of various anesthetic agents have been studied at length. Very little is known about potential effects of anesthesia on brain structure. In this study we used Diffusion Tensor Imaging to compare the white matter microstructure of healthy control subjects under sevoflurane anesthesia with their awake state. Fractional Anisotropy, a white mater integrity index, transiently decreases throughout the brain during sevoflurane anesthesia and then returns back to baseline. Other DTI metrics such as mean diffusivity, axial diffusivity and radial diffusivity were increased under sevoflurane anesthesia. Although DTI metrics are age dependent, the transient changes due to sevoflurane were independent of age and sex. Volumetric analysis shows various white matter volumes decreased whereas some gray matter volumes increased during sevoflurane anesthesia. These results suggest that sevoflurane anesthesia has a significant, but transient, effect on white matter microstructure. In spite of the transient effects of sevoflurane anesthesia there were no measurable effects on brain white matter as determined by the DTI metrics at 2 days and 7 days following anesthesia. The role of white matter in the loss of consciousness under anesthesia will need to be studied and MRI studies with subjects under anesthesia will need to take these results into account.

Summary Delirium and postoperative neurocognitive disorder are the commonest perioperative complications in patients more than 65 yr of age. However, data suggest that we often fail to screen patients for preoperative cognitive impairment, to warn patients and families of risk, and to take preventive measures to reduce the incidence of perioperative neurocognitive disorders. As part of the American Society of Anesthesiologists (ASA) Perioperative Brain Health Initiative, an international group of experts was invited to review published best practice statements and guidelines. The expert group aimed to achieve consensus on a small number of practical recommendations that could be implemented by anaesthetists and their partners to reduce the incidence of perioperative neurocognitive disorders. Six statements were selected based not only on the strength of the evidence, but also on the potential for impact and the feasibility of widespread implementation. The actions focus on education, cognitive and delirium screening, non-pharmacologic interventions, pain control, and avoidance of antipsychotics. Strategies for effective implementation are discussed. Anaesthetists should be key members of multidisciplinary perioperative care teams to implement these recommendations.

Background Context As increasing numbers of elderly Americans undergo spinal surgery, it is important to identify which patients are at highest risk for poor cognitive and functional recovery. Frailty is a geriatric syndrome that has been closely linked to poor outcomes, and short-form screening may be a helpful tool for preoperative identification of at-risk patients. Purpose This study aimed to conduct a pilot study on the usefulness of a short-form screening tool to identify elderly patients at increased risk for prolonged cognitive and functional recovery following elective spine surgery. Study Design/Setting This is a prospective, comparative cohort study. Patient Sample The sample comprised 100 patients over age 65 who underwent elective spinal surgery (cervical or lumbar) at a single, large academic medical center from 2013 to 2014. Outcome Measures Fatigue, Resistance, Ambulation, Illnesses, Loss of Weight (FRAIL) scale, Postoperative Quality of Recovery Scale (PQRS), and instrumental activities of daily living (IADL) scores were the outcome measures. Methods Included patients were assessed with the FRAIL scale and stratified as robust, pre-frail, or frail. The PQRS and IADL scores were also obtained. Patients were re-examined at 1 day, 3 days, 1 month, and 3 months after surgery for cognitive recovery at 3 months, and secondarily, functional recovery at 3 months. Results At 3 months, only 50% of frail patients had recovered to their cognitive baseline compared with 60.7% of pre-frail and 69.2% of robust patients (trend). At 3 months, 66.7% of frail patients had recovered to their functional baseline compared with 57% of pre-frail and 76.9% of robust patients (trend). Using multivariate regression modeling, at 3 months, frail patients were less likely to have recovered to their cognitive baseline compared with pre-frail and robust patients (odds ratio 0.39, confidence interval 0.131–1.161). Conclusions This pilot study demonstrates a trend toward poorer cognitive recovery 3 months following elective spinal surgery for frail patients. Frailty screening can help preoperatively identify patients who may experience protracted cognitive and functional recovery.

BACKGROUND: Mechanistic aspects of cognitive recovery after anesthesia and surgery are not yet well-characterized, but may be vital to distinguishing the contributions of anesthesia and surgery in cognitive complications common in the elderly such as delirium and postoperative cognitive dysfunction (POCD). This paper describes the aims and methodological approach to the ongoing study, Trajectory of Recovery in the Elderly (TORIE), that focuses on the trajectory of cognitive recovery from general anesthesia. METHODS: The study design employs cognitive testing coupled with neuroimaging techniques such as functional magnetic resonance imaging, diffusion tensor imaging, and arterial spin labeling to characterize cognitive recovery from anesthesia and its biological correlates. Applying these techniques to a cohort of age-specified healthy volunteers 40 to 80 years old, who are exposed to general anesthesia alone, in the absence of surgery, will assess cognitive and functional neural network recovery after anesthesia. Imaging data are acquired prior, during, and immediately after anesthesia, as well as 1 and 7 days after. Detailed cognitive data are captured at the same time points as well as 30 days after anesthesia, and brief cognitive assessments are repeated at 6 and 12 months after anesthesia. RESULTS: The study is underway. Our primary hypothesis is that older adults may require significantly longer to achieve cognitive recovery, measured by Postoperative Quality of Recovery Scale (PQRS) cognitive domain, than younger adults in the immediate post-anesthesia period, but all will fully recover to baseline levels within 30 days of anesthesia exposure. Imaging data will address systems neuroscience correlates of cognitive recovery from general anesthesia. CONCLUSIONS: The data acquired in this project will have both clinical and theoretical relevance regardless of the outcome by delineating the mechanism behind short term recovery across the adult age lifespan, which will have major implications for our understanding of the effects of anesthetic drugs.

Background Aortic valve replacement is a high-risk surgery (3%-5%, 30-day mortality) performed on approximately 30,000 elderly patients a year in the United States. Currently, preoperative risk assessment is based on a composite of medical examination and a subjective evaluation for frailty ("eyeball test"). Objective frailty assessment using validated indices has the potential to improve risk stratification. The purpose of this study was to (1) establish whether frailty can predict 30-day mortality and composite morbidity in patients undergoing aortic valve replacement and (2) compare the predictive ability of 3 frailty indices in this population. Methods This study was a retrospective cohort study of 3088 patients 65 years old and older undergoing aortic valve replacement surgery (based on current procedure terminology codes) between the years 2006 and 2012 extracted from the American College of Surgeons National Surgical Quality Improvement Program database. Frailty was assessed using the modified frailty index, risk analysis index, and Ganapathi indices. Outcomes measured were 30-day mortality and composite morbidity (myocardial infarction, cardiac arrest, pulmonary embolism, pneumonia, reintubation, renal insufficiency, coma >24 hours, urinary tract infections, sepsis, deep vein thrombosis, deep wound surgical site infection, superficial site infection, and reoperation). Results Frailty was a better predictor of mortality than morbidity, and it was not markedly different among any of the 3 indices. Frailty was associated with an increased risk of 30-day mortality and longer lengths of stay. Conclusions Frailty can predict mortality in patients undergoing aortic valve replacement. Choice of frailty index does not make a difference in this patient population.

Objective Establish whether POCD is associated with new disability after surgery, which would inform whether POCD impacts patient-centered outcomes. Background POCD is a decline in neuropsychiatric tests scores from presurgical baseline which occurs in approximately 15% of older patients 3 months after surgery. POCD is a research construct meant to investigate patient and family reports of older adults who were "never the same after surgery." However, many patients with POCD do not perceive difficulty with thinking and memory, and the question remains whether POCD impacts patient function. Methods We performed a prospective cohort study of 167 older adults undergoing major noncardiac surgery (requiring at least a 2-day hospital stay). Exclusion criteria were: history of dementia, cardiac or intracranial procedure, inability to consent for themselves, or emergency surgery. We administered formal neuropsychiatric testing (Alzheimer Disease Research Center UDS battery), basic and instrumental activities of daily living (Alzheimer Disease Research Center IADLs), pain (geriatric pain measure), and depression screening (hospital depression and anxiety scale) before and 3 months after surgery. We recorded all patient refined diagnostic related groups codes, blood pressure, anesthetics and narcotics administered, surgical and anesthesia duration, and measured complications and severity, length of stay, and readmissions. Results Patients with POCD (21/167, 14.1%) had twice the proportion of new impairment in IADL as compared to those without POCD (57% vs 27%, P = .01). The most common areas of decline were social activities, ability to find items around the house, remember appointments, shop and pay for items, do laundry, drive a car/use public transport, and do housework. Predictors of IADL change after surgery included POCD, presurgical cognition, presurgical function, postoperative depression, and the development of postoperative complications. Conclusions Patients with POCD experience a much higher incidence of new disability after surgery. Baseline cognitive or functional limitations are also risk factors for new disability. Many patients are not aware of their limitations before surgery. Future study is needed to identify practical ways to routinely screen patients and reduce risk. Patients need to be informed of their risk for new disability after surgery to inform their medical decision making.

Background Postoperative neurocognitive disorders may arise in part from adverse effects of general anaesthetics on the CNS, especially in older patients or individuals otherwise vulnerable to neurotoxicity because of systemic disease or the presence of pre-existing neuropathology. Previous studies have documented cytokine and injury biomarker responses to surgical procedures that included general anaesthesia, but it is not clear to what degree anaesthetics contribute to these responses. Methods We performed a prospective cohort study of 59 healthy volunteers aged 40–80 yr who did not undergo surgery. Plasma markers of neurological injury and inflammation were measured immediately before and 5 h after induction of general anaesthesia with 1 minimum alveolar concentration of sevoflurane. Biomarkers included interleukin-6 (IL-6), tumour necrosis factor alpha (TNF-α), C-reactive protein (CRP), and neural injury (tau, neurofilament light [NF-L], and glial fibrillary acidic protein [GFAP]). Results Baseline biomarkers were in the normal range, although NF-L and GFAP were elevated as a function of age. At 5 h after induction of anaesthesia, plasma tau, NF-L, and GFAP were significantly decreased relative to baseline. Plasma IL-6 was significantly increased after anaesthesia, but by a biologically insignificant degree ( Conclusions Sevoflurane general anaesthesia without surgery, even in older adults, did not provoke an inflammatory state or neuronal injury at a concentration that is detectable by an acute elevation of measured plasma biomarkers in the early hours after exposure. Clinical trial registration NCT02275026.

Though a growing body of literature is addressing the possible longer-term cognitive effects of anesthetics, to date no study has delineated the normal trajectory of neural recovery due to anesthesia alone in older adults. We obtained resting state functional magnetic resonance imaging scans on 62 healthy human volunteers between ages forty and eighty before, during, and after sevoflurane (general) anesthesia, in the absence of surgery, as part of a larger study on cognitive function post-anesthesia. Resting state networks expression decreased consistently one hour after emergence from anesthesia. This corresponded to a global reduction in anticorrelated functional connectivity post-anesthesia, seen across individual regions-of-interest. Positively correlated functional connectivity remained constant across peri-anesthetic states. All measures returned to baseline 1 day later, with individual regions-of-interest essentially returning to their pre-anesthesia connectivity levels. These results define normal peri-anesthetic changes in resting state connectivity in healthy older adults.

Frailty, a state of decreased physiological reserve, is strongly associated with perioperative mortality in older adults. However, the mechanism by which frailty is associated with mortality is not yet understood. Autonomic dysfunction in the form of decreased intraoperative hemodynamic variability has been shown to be associated with increased mortality. We aimed to see whether frail patients have less hemodynamic variability under anesthesia and whether variability mediates the relationship between frailty and 30-day mortality.We performed a single-center retrospective study of 1223 patients ≥65 years of age undergoing surgery between July 2008 and December 2012. We used markers of frailty: age70, preoperative body mass index18.5, hematocrit35%, albumin3.4 g/dL, and creatinine2.0 mg/dL. We modeled the outcome of 30-day mortality with number of frailty conditions adjusting for gender, length of surgery, American Society of Anesthesiologists class, and need for transfusion. Intraoperative hemodynamic variability was defined as the count of episodes of absolute change15% in fractional mean arterial pressure (MAP) between consecutive 5-minute intervals. We evaluated the role of intraoperative hemodynamic variability as a mediator (modifier) of the relationship between frailty and mortality, checking for 3 conditions: (1) frailty must affect episodes of absolute change15% in fractional MAP; (2) episodes of absolute change15% in fractional MAP must affect 30-day mortality; and (3) mediation effect is significant. We used the product method, in which the mediation effect was estimated as the product of the first 2 relationships. Then we applied the percentile bootstrap method to obtain the 95% CI for the estimate of mediation effect.Number of frailty conditions and episodes of absolute change15% in fractional MAP were inversely proportional. Presence of ≥4 frailty conditions was associated with40% reduction of the number of episodes of absolute change15% in fractional MAP. Regarding mortality, episodes of absolute change15% in fractional MAP were protective. The addition of absolute change15% in fractional MAP in the mortality model resulted in a decrease in the frailty odds ratio from 10.6 to 9.1 (4+ conditions), suggesting that episodes of absolute change15% in fractional MAP are indeed a mediator. The mediation effect was modest; 5 episodes of absolute change15% in fractional MAP was 5.2%, 6.4%, 6.9%, and 9.0% for frailty conditions from 1 to 4+, respectively.Frailty is associated with less intraoperative blood pressure variation, and the relationship of frailty with 30-day mortality is partially mediated by episodes of absolute change15% in fractional MAP. This suggests that autonomic dysregulation may be a modest part of the mechanism behind the association between frailty and perioperative mortality. Our finding is consistent with recent literature, suggesting that an intact autonomic nervous system confers lower perioperative mortality.

Background Few perioperative studies have assessed subjective cognitive complaint (SCC) in combination with neuropsychological testing. New nomenclature guidelines require both SCC and objective decline on cognitive testing. The objective of our study was to compare SCC and neuropsychological testing in an elderly surgical cohort. Methods This was a secondary analysis of a prospective cohort trial at a single urban medical centre. We included patients older than 65 yr, undergoing major non-cardiac surgery with general anaesthesia. Those with dementia or inability to consent were excluded, as were those undergoing emergency, cardiac, or intracranial procedures. Patients completed a neuropsychiatry battery before and 3 months after surgery. SCC was defined utilising the single question: ‘do you feel that surgery and anaesthesia have impacted your clarity of thought?' Objective cognitive decline was defined as 1 standard deviation decline from the baseline of the cohort. Results Of the 120 patients who completed assessments, 16/120 (13%) had SCC after surgery, and 41/120 (34%) had objective decline. The sensitivity of SCC in relation to objective decline was 24% and specificity was 92%. Of the patients with SCC, 43.8% were screened positive for depression after surgery compared with 4.9% without SCC; P=0.001. Conclusions Many patients with objective cognitive decline did not report SCC. There appears to be a relationship between SCC and depression. The use of SCC in surgical patients to define postoperative neurocognitive disorders needs to be better delineated. Clinical trial registration NCT02650687.

There is significant evidence that many older surgical patients experience at least a transient decrease in cognitive function. Although there is still equipoise regarding the degree, duration, and mechanism of cognitive dysfunction, there is a concurrent need to provide best-practice clinical evidence. The two major cognitive disorders seen after surgery are postoperative delirium and postoperative cognitive dysfunction. Delirium is a public health problem; millions of dollars are spent annually on delirium-related medical resource use and prolonged hospital stays. Postoperative cognitive dysfunction is a research construct that historically signifies decline in performance on a neuropsychiatric test or group of tests and begins days to weeks after surgery. This review focuses on the current state of information gathered by several interdisciplinary stakeholder groups. Although there is still a need for high-level evidence to guide clinical practice, there is an emerging literature that can guide practitioners.

Background and objectivesChronic postsurgical pain in patients over 65 negatively impacts recovery, quality of life and physical functioning. In the community setting, chronic pain has been shown to be related to frailty, a syndrome more commonly seen in older adults and characterized by limited physiologic reserve and ability to withstand stressors. While frailty is an important preoperative risk factor for poor surgical outcomes in older adults, the relationship between frailty and postsurgical pain in this population has not been investigated. We hypothesized that preoperative frailty would be associated with greater odds of postsurgical chronic pain.MethodsWe conducted a prospective cohort study of 116 patients older than 65 years old who underwent major elective non-cardiac surgery. Patients were assessed for frailty within 30 days prior to surgery using the FRAIL Scale assessment and pain was evaluated before surgery and at 3 months after surgery using the Geriatric Pain Measure.ResultsAfter adjusting for baseline characteristics, we found that frail patients were almost five times more likely to have intrusive postsurgical pain compared with patients who were not frail (OR 4.73, 95% CI 1.24 to 18.09). Intrusive preoperative pain and spine surgery were also associated with increased postsurgical pain (OR 10.13, 95% CI 2.81 to 36.57 and OR 4.02, 95% CI 1.22 to 13.17, respectively).ConclusionAlthough future studies are needed to establish a causal relationship between preoperative frailty and postsurgical pain, our findings suggest that older patients should have preoperative frailty assessments and frail older adults may need additional resources to improve postsurgical pain outcomes.Trial registration numberNCT02650687

Purpose Geriatric patients are more sensitive to the anesthetic effects of propofol and its adverse effects, such as hypotension, than is the general population; thus, a reduced dose (1–1.5 mg/kg) is recommended for the induction of anesthesia. The extent to which clinicians follow established dosing guidelines has not been well described. Therefore, we investigated the prevalence of propofol overdose in the elderly population to determine whether propofol overdose occurs and is associated with increased hypotension and 30-day mortality. Methods In this retrospective study in patients who received propofol for the induction of general anesthesia, data on demographic characteristics, preoperative medications, intraoperative management, and 30-day mortality were collected. The dose of propofol used for the induction of anesthesia and the median blood pressure in the pre- and immediate postinduction periods were determined. Hypotension was defined as either: (1) a decrease in mean arterial pressure (MAP) of >40% concurrent with a MAP of Findings A total of 17,540 patients were included in the analysis; 4033 (23.0%) were aged >65 years. The median (interquartile range) propofol dose in the group aged >65 years was 1.8 (1.4–2.2) mg/kg, above the recommended dose, in comparison to 2.2 (1.9–2.5) mg/kg in younger patients. On multivariate analysis, increased propofol dose was associated with increased postinduction hypotension, especially in patients over 70 years of age, but not 30-day mortality. Implications Older patients received greater-than-recommended doses of propofol for induction, which may have led to significant dose-dependent hypotension. Despite this finding, the dose of propofol for induction was not independently associated with a greater 30-day mortality rate. More education regarding geriatric concerns is needed for encouraging anesthesiologists to tailor the plan for anesthesia in geriatric patients. However, overall postsurgical mortality is a function of preoperative risk and type surgical procedure.

Purpose Postoperative cognitive dysfunction (POCD) is a serious and costly complication of the elderly; even mild impairment has the potential to impact overall well being. Anesthesiologists continue to search for ways to manipulate intraoperative technique to optimize postoperative cognition in the elderly. Depth of anesthesia during surgery is an area that has shown some promise for short-term outcomes, such as delirium. However, excessive depth has both positive and negative associations with longer-term POCD. We hypothesize that this uncertainty is due to the inability of median depth to capture the amount of burst suppression or electrical silence. In this study, our purpose was to identify the intraoperative processed EEG parameters that are most closely correlated with POCD. Methods To explore the association of several processed EEG parameters with POCD, we performed a retrospective analysis of a cohort of 105 patients aged >68 years scheduled for major surgery under general anesthesia. Intraoperative medications, hemodynamics, processed EEG and cerebral oxygen saturation were recorded. All patients had a cognitive battery before surgery and repeated at 3 months afterward. Findings One hundred and five patients enrolled and 77 (73.3%) patients completed the 3-month cognitive testing. The incidence of POCD was 27%; the median Bispectral Index value for patients who developed POCD was similar to patients who did not (46 vs 42 minutes). However, patients who developed POCD spent less time with Bispectral Index P = 0.01) and burst suppression (35 vs 96 minutes, P = 0.04). Hypotension, cerebral desaturation, and use of total intravenous anesthesia were similar between patients with and without POCD. Implications Patients who developed POCD spent less time in EEG burst suppression and less time in deep states. Burst suppression may be protective for POCD. Further work is needed to definitively identify the role of burst suppression in the context of other patient and intraoperative variables to prevent POCD.

Spine surgery is one of the most common surgeries for adults greater than 65 years of age. Optimizing and caring for the elderly patient presenting for spine surgery requires planning and multidisciplinary input from surgeons, primary care physicians, and anesthesiologists. Controversies exist surrounding appropriate perioperative management of complicated chronic medication regimens and the ideal selection of intraoperative therapy for these patients. In this article we present an overview of the controversies anesthesiologists face as they work with the elderly patient's primary doctor and surgical team to achieve a safe perioperative course. Specifically, we discuss the interaction of geriatric physiology and pathophysiology with medications used in the perioperative period. While care of the geriatric spine surgery patient is nuanced, the anesthesiologist can work together with medical personnel, surgeons, and pharmacy to provide safe and effective care.

The All Patient Refined Diagnosis Related Group (APR-DRG) is an inpatient visit classification system that assigns a diagnostic related group, a Risk of Mortality (ROM) subclass and a Severity of Illness (SOI) subclass. While extensively used for cost adjustment, no study has compared the APR-DRG subclass modifiers to the popular Charlson Comorbidity Index as a measure of comorbidity severity in models for perioperative in-hospital mortality. In this study we attempt to validate the use of these subclasses to predict mortality in a cohort of surgical patients. We analyzed all adult (age over 18 years) inpatient non-cardiac surgery at our institution between December 2005 and July 2013. After exclusions, we split the cohort into training and validation sets. We created prediction models of inpatient mortality using the Charlson Comorbidity Index, ROM only, SOI only, and ROM with SOI. Models were compared by receiver-operator characteristic (ROC) curve, area under the ROC curve (AUC), and Brier score. After exclusions, we analyzed 63,681 patient-visits. Overall in-hospital mortality was 1.3%. The median number of ICD-9-CM diagnosis codes was 6 (Q1–Q3 4–10). The median Charlson Comorbidity Index was 0 (Q1–Q3 0–2). When the model was applied to the validation set, the c-statistic for Charlson was 0.865, c-statistic for ROM was 0.975, and for ROM and SOI combined the c-statistic was 0.977. The scaled Brier score for Charlson was 0.044, Brier for ROM only was 0.230, and Brier for ROM and SOI was 0.257. The APR-DRG ROM or SOI subclasses are better predictors than the Charlson Comorbidity Index of in-hospital mortality among surgical patients.

Over one-third of the surgeries in the United States are performed on patients aged 65 and older, and delirium is one of the most common postoperative complications in this population. Postoperative delirium is a heterogeneous disorder, and as such it is not surprising that the reported predisposing and precipitating factors are widely variable. Knowledge of the risk factors that predict postoperative delirium will aid in early identification of patients at highest risk in order to allow targeted use of resources including geriatric consults, specialized units, and nonpharmacologic interventions.

The fastest growing segment of the population is individuals over the age of 65 years, resulting in an ever-growing need for surgical procedures in aging patients. Changes in mental function after surgery are common in geriatric patients. Here we review two similar, yet distinct clinical diagnoses of postoperative cognitive impairment, both of which are associated with significantly increased morbidity and mortality. Inattention and disorganized thinking in the setting of an acute change in consciousness are hallmarks of postoperative delirium (PD). Postoperative cognitive dysfunction (POCD) is a research construct characterized by decline in cognitive performance compared to a baseline exam. PD typically occurs in the first few days after surgery, while POCD is identified in the weeks to months after surgery. Pathophysiologic mechanisms for PD and POCD have significant overlap, and current research implicates general health status, altered neurotransmission, inflammation, oxidative stress, and disruption of the circadian clock. Awareness of certain perioperative factors, some of which are modifiable, is important for risk stratification and for optimization of care to minimize postoperative cognitive impairment. Preoperative, intraoperative, and postoperative risk factors are discussed in detail. Health professionals caring for postsurgical patients should be trained to recognize and document signs and symptoms associated with delirium using one of the validated assessments presented. Several pharmacologic and non-pharmacologic interventions are discussed for the treatment of postoperative cognitive impairment, along with a review of the current best practice guidelines from the American Geriatrics Society Expert Panel on Postoperative Delirium in Older Adults.

Importance Postoperative delirium occurs in 10% to 60% of elderly patients having major surgery and is associated with longer hospital stays, increased hospital costs, and 1-year mortality. Emerging literature suggests that dexmedetomidine sedation in critical care units is associated with reduced incidence of delirium. However, intraoperative use of dexmedetomidine for prevention of delirium has not been well studied. Objective To evaluate whether an intraoperative infusion of dexmedetomidine reduces postoperative delirium. Design, Setting, and Participants This study was a multicenter, double-blind, randomized, placebo-controlled trial that randomly assigned patients to dexmedetomidine or saline placebo infused during surgery and for 2 hours in the recovery room. Patients were assessed daily for postoperative delirium (primary outcome) and secondarily for postoperative cognitive decline. Participants were elderly (>68 years) patients undergoing major elective noncardiac surgery. The study dates were February 2008 to May 2014. Interventions Dexmedetomidine infusion (0.5 µg/kg/h) during surgery and up to 2 hours in the recovery room. Main Outcomes and Measures The primary hypothesis tested was that intraoperative dexmedetomidine administration would reduce postoperative delirium. Secondarily, the study examined the correlation between dexmedetomidine use and postoperative cognitive change. Results In total, 404 patients were randomized; 390 completed in-hospital delirium assessments (median [interquartile range] age, 74.0 [71.0-78.0] years; 51.3% [200 of 390] female). There was no difference in postoperative delirium between the dexmedetomidine and placebo groups (12.2% [23 of 189] vs 11.4% [23 of 201],P = .94). After adjustment for age and educational level, there was no difference in the postoperative cognitive performance between treatment groups at 3 months and 6 months. Adverse events were comparably distributed in the treatment groups. Conclusions and Relevance Intraoperative dexmedetomidine does not prevent postoperative delirium. The reduction in delirium previously demonstrated in numerous surgical intensive care unit studies was not observed, which underscores the importance of timing when administering the drug to prevent delirium. Trial Registration clinicaltrials.gov IdentifierNCT00561678

Under a long-standing collaboration with the John A. Hartford Foundation (JAHF), the Atlantic Philanthropies (AP), and specialty societies in 10 targeted specialties, the American Geriatrics Society (AGS) has been working to improve quality of care provided to older adults by surgical and related medical specialists. To support and nurture future academic leaders, the Geriatrics-for-Specialists Initiative (GSI) established the Dennis W. Jahnigen Career Development Scholar Award (JCDA) program in 2002, with AP joining JAHF as a core funder of the awards in 2003. Commencing in 2011, the National Institute on Aging (NIA) launched the Grants for Early Medical/Surgical Specialists’ Transition to Aging Research (GEMSSTAR) program, using an RO3 mechanism. Recipients of the JCDA and the GEMSSTAR are provided with 2 years of research support and networking opportunities with other scholars; 79 JCDA and 26 surgical and related medical specialty GEMSSTAR scholars have been funded through these award mechanisms, with AGS, JAHF, and surgical and related medical specialty societies providing matching support for 20 of the GEMSSTAR scholars for leadership development programs. One of the primary criteria for judging the overall success of the program was eventual transition of the award to a federally funded program, which was achieved when NIA launched the GEMSSTAR program in 2011.

The abstracted set of recommendations presented here provides essential guidance both on the prevention of postoperative delirium in older patients at risk of delirium and on the treatment of older surgical patients with delirium, and is based on the 2014 American Geriatrics Society (AGS) Guideline. The full version of the guideline, American Geriatrics Society Clinical Practice Guideline for Postoperative Delirium in Older Adults is available at the website of the AGS. The overall aims of the study were twofold: first, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the prevention of postoperative delirium in older adults; and second, to present nonpharmacologic and pharmacologic interventions that should be implemented perioperatively for the treatment of postoperative delirium in older adults. Prevention recommendations focused on primary prevention (i.e., preventing delirium before it occurs) in patients who are at risk for postoperative delirium (e.g., those identified as moderate-to-high risk based on previous risk stratification models such as the National Institute for Health and Care Excellence (NICE) guidelines, Delirium: Diagnosis, Prevention and Management. Clinical Guideline 103; London (UK): 2010 July 29). For management of delirium, the goals of this guideline are to decrease delirium severity and duration, ensure patient safety and improve outcomes.