Person:

Travison, Thomas

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.

INTRODUCTION Since the relationship between delirium and long-term cognitive decline has not been well-explored, we evaluated this association in a prospective study.

METHODS SAGES is an on-going study involving 560 adults age 70+ without dementia scheduled for major surgery. Delirium was assessed daily in the postoperative period using the Confusion Assessment Method. General Cognitive Performance (GCP) and the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE) were assessed preoperatively then repeatedly out to 36 months.

RESULTS On average, patients with post-operative delirium had significantly lower preoperative cognitive performance, greater immediate (1 month) impairment, equivalent recovery at 2 months, and significantly greater long-term cognitive decline relative to the non-delirium group. Proxy reports corroborated the clinical significance of the long-term cognitive decline in delirious patients.

DISCUSSION Cognitive decline following surgery is biphasic and accelerated among persons with delirium. The pace of long-term decline is similar to that seen with Mild Cognitive Impairment.

Background Cognitive impairment is a well-recognized risk factor for delirium. Our goal was to determine if the level of cognitive performance across the non-demented cognitive ability spectrum is correlated with delirium risk, and to gauge the importance of cognition relative to other known risk factors for delirium.

Methods The SAGES (Successful Aging after Elective Surgery) study enrolled 566 adults age ≥ 70 years scheduled for major surgery. Patients were assessed preoperatively and daily during hospitalization for the occurrence of delirium using the Confusion Assessment Method. Cognitive function was assessed preoperatively with an 11-test neuropsychological battery combined into a composite score for general cognitive performance (GCP). We examined the risk for delirium attributable to GCP, as well as demographic factors, vocabulary ability, and informant-rated cognitive decline, and compared the strength of association to risk factors identified in a previously published delirium prediction rule for delirium.

Results Delirium occurred in 135 (24%) patients. Lower GCP score was strongly and linearly predictive of delirium risk (RR = 2.0 per each half standard deviation difference in GCP score, 95% confidence interval, 1.5, 2.5). This effect was not attenuated by statistical adjustment for demographics, vocabulary ability, and informant-rated cognitive decline. The effect was stronger than, and largely independent from, both standard delirium risk factors and comorbidity.

Conclusions Risk of delirium is linearly and strongly related to presurgical cognitive performance level even at levels above the population median, which would be considered unimpaired.