Yohei Nomura1, Mitsunori Nakano2, Brian Bush2, Jing Tian3, Atsushi Yamaguchi1, Jeremy Walston4, Rani Hasan5, Kenton Zehr6, Kaushik Mandal6, Andrew LaFlam7, Karin J Neufeld8, Vidyulata Kamath9, Charles W Hogue10, Charles H Brown2. 1. From the Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan. 2. Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland. 3. Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland. 4. Department of Geriatrics and Gerontology. 5. Department of Medicine. 6. Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. 7. School of Medicine, Tufts University, Medford, Massachusetts. 8. Department of Psychiatry and Behavioral Sciences. 9. Division of Medical Psychology, Johns Hopkins University School of Medicine, Baltimore, Maryland. 10. Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Abstract
BACKGROUND: Frailty is a geriatric syndrome thought to identify the most vulnerable older adults, and morbidity and mortality has been reported to be higher for frail patients after cardiac surgery compared to nonfrail patients. However, the cognitive consequences of frailty after cardiac surgery have not been well described. In this study, we examined the hypothesis that baseline frailty would be associated with postoperative delirium and cognitive change at 1 and 12 months after cardiac surgery. METHODS: This study was nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. Before surgery, patients were assessed with the validated "Fried" frailty scale, which evaluates 5 domains (shrinking, weakness, exhaustion, low physical activity, and slowed walking speed) and classifies patients as nonfrail, prefrail, and frail. The primary outcome was postoperative delirium during hospitalization, which was assessed using the Confusion Assessment Method, Confusion Assessment Method for the Intensive Care Unit, and validated chart review. Neuropsychological testing was a secondary outcome and was generally performed within 2 weeks of surgery and then 4-6 weeks and 1 year after surgery, and the outcome of interest was change in composite Z-score of the test battery. Associations were analyzed using logistic and linear regression models, with adjustment for variables considered a priori (age, gender, race, education, and logistic European System for Cardiac Operative Risk Evaluation). Multiple imputation was used to account for missing data at the 12-month follow-up. RESULTS: Data were available from 133 patients with baseline frailty assessments. Compared to nonfrail patients (13% delirium incidence), the incidence of delirium was higher in prefrail (48% delirium incidence; risk difference, 35%; 95% CI, 10%-51%) and frail patients (48% delirium incidence; risk difference, 35%; 95% CI, 7%-53%). In both univariable and multivariable models, the odds of delirium were significantly higher for prefrail (adjusted odds ratio, 6.43; 95% CI, 1.31-31.64; P = .02) and frail patients (adjusted odds ratio, 6.31; 95% CI, 1.18-33.74; P = .03) compared to nonfrail patients. The adjusted decline in composite cognitive Z-score was greater from baseline to 1 month only in frail patients compared to nonfrail patients. By 1 year after surgery, there were no differences in the association of baseline frailty with change in cognition. CONCLUSIONS: Compared to nonfrail patients, both prefrail and frail patients were at higher risk for the primary outcome of delirium after cardiac surgery. Frail patients were also at higher risk for the secondary outcome of greater decline in cognition from baseline to 1 month, but not baseline to 1 year, after surgery.
BACKGROUND: Frailty is a geriatric syndrome thought to identify the most vulnerable older adults, and morbidity and mortality has been reported to be higher for frail patients after cardiac surgery compared to nonfrail patients. However, the cognitive consequences of frailty after cardiac surgery have not been well described. In this study, we examined the hypothesis that baseline frailty would be associated with postoperative delirium and cognitive change at 1 and 12 months after cardiac surgery. METHODS: This study was nested in 2 trials, each of which was conducted by the same research team with identical measurement of exposures and outcomes. Before surgery, patients were assessed with the validated "Fried" frailty scale, which evaluates 5 domains (shrinking, weakness, exhaustion, low physical activity, and slowed walking speed) and classifies patients as nonfrail, prefrail, and frail. The primary outcome was postoperative delirium during hospitalization, which was assessed using the Confusion Assessment Method, Confusion Assessment Method for the Intensive Care Unit, and validated chart review. Neuropsychological testing was a secondary outcome and was generally performed within 2 weeks of surgery and then 4-6 weeks and 1 year after surgery, and the outcome of interest was change in composite Z-score of the test battery. Associations were analyzed using logistic and linear regression models, with adjustment for variables considered a priori (age, gender, race, education, and logistic European System for Cardiac Operative Risk Evaluation). Multiple imputation was used to account for missing data at the 12-month follow-up. RESULTS: Data were available from 133 patients with baseline frailty assessments. Compared to nonfrail patients (13% delirium incidence), the incidence of delirium was higher in prefrail (48% delirium incidence; risk difference, 35%; 95% CI, 10%-51%) and frail patients (48% delirium incidence; risk difference, 35%; 95% CI, 7%-53%). In both univariable and multivariable models, the odds of delirium were significantly higher for prefrail (adjusted odds ratio, 6.43; 95% CI, 1.31-31.64; P = .02) and frail patients (adjusted odds ratio, 6.31; 95% CI, 1.18-33.74; P = .03) compared to nonfrail patients. The adjusted decline in composite cognitive Z-score was greater from baseline to 1 month only in frail patients compared to nonfrail patients. By 1 year after surgery, there were no differences in the association of baseline frailty with change in cognition. CONCLUSIONS: Compared to nonfrail patients, both prefrail and frail patients were at higher risk for the primary outcome of delirium after cardiac surgery. Frail patients were also at higher risk for the secondary outcome of greater decline in cognition from baseline to 1 month, but not baseline to 1 year, after surgery.
Authors: Jonathan Afilalo; Salvatore Mottillo; Mark J Eisenberg; Karen P Alexander; Nicolas Noiseux; Louis P Perrault; Jean-Francois Morin; Yves Langlois; Samuel M Ohayon; Johanne Monette; Jean-Francois Boivin; David M Shahian; Howard Bergman Journal: Circ Cardiovasc Qual Outcomes Date: 2012-03-06
Authors: Jonathan Afilalo; Sandra Lauck; Dae H Kim; Thierry Lefèvre; Nicolo Piazza; Kevin Lachapelle; Giuseppe Martucci; Andre Lamy; Marino Labinaz; Mark D Peterson; Rakesh C Arora; Nicolas Noiseux; Andrew Rassi; Igor F Palacios; Philippe Généreux; Brian R Lindman; Anita W Asgar; Caroline A Kim; Amanda Trnkus; José A Morais; Yves Langlois; Lawrence G Rudski; Jean-Francois Morin; Jeffrey J Popma; John G Webb; Louis P Perrault Journal: J Am Coll Cardiol Date: 2017-07-07 Impact factor: 24.094
Authors: L P Fried; C M Tangen; J Walston; A B Newman; C Hirsch; J Gottdiener; T Seeman; R Tracy; W J Kop; G Burke; M A McBurnie Journal: J Gerontol A Biol Sci Med Sci Date: 2001-03 Impact factor: 6.053
Authors: Charles H Brown; Candice Morrissey; Masahiro Ono; Gayane Yenokyan; Ola A Selnes; Jeremy Walston; Laura Max; Andrew LaFlam; Karin Neufeld; Rebecca F Gottesman; Charles W Hogue Journal: J Am Geriatr Soc Date: 2015-01 Impact factor: 5.562
Authors: Sharon K Inouye; Linda Leo-Summers; Ying Zhang; Sidney T Bogardus; Douglas L Leslie; Joseph V Agostini Journal: J Am Geriatr Soc Date: 2005-02 Impact factor: 5.562
Authors: Jane S Saczynski; Edward R Marcantonio; Lien Quach; Tamara G Fong; Alden Gross; Sharon K Inouye; Richard N Jones Journal: N Engl J Med Date: 2012-07-05 Impact factor: 91.245
Authors: Andrew N Stammers; D Scott Kehler; Jonathan Afilalo; Lorraine J Avery; Sean M Bagshaw; Hilary P Grocott; Jean-Francois Légaré; Sarvesh Logsetty; Colleen Metge; Thang Nguyen; Kenneth Rockwood; Jitender Sareen; Jo-Ann Sawatzky; Navdeep Tangri; Nicholas Giacomantonio; Ansar Hassan; Todd A Duhamel; Rakesh C Arora Journal: BMJ Open Date: 2015-03-09 Impact factor: 2.692
Authors: Elizabeth Mahanna-Gabrielli; Kathy Zhang; Frederick E Sieber; Hung Mo Lin; Xiaoyu Liu; Margaret Sewell; Stacie G Deiner; Kenneth S Boockvar Journal: Anesth Analg Date: 2020-06 Impact factor: 5.108
Authors: Mitsunori Nakano; Yohei Nomura; Giancarlo Suffredini; Brian Bush; Jing Tian; Atsushi Yamaguchi; Jeremy Walston; Rani Hasan; Kaushik Mandal; Stefano Schena; Charles W Hogue; Charles H Brown Journal: Anesth Analg Date: 2020-06 Impact factor: 5.108
Authors: Marta Wleklik; Quin Denfeld; Magdalena Lisiak; Michał Czapla; Marta Kałużna-Oleksy; Izabella Uchmanowicz Journal: Int J Environ Res Public Health Date: 2022-02-16 Impact factor: 3.390