Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change

Yohei Nomura, Mitsunori Nakano, Brian Bush, Jing Tian, Atsushi Yamaguchi, Jeremy Walston, Rani Hasan, Kenton Zehr, Kaushik Mandal, Andrew LaFlam, Karin J. Neufeld, Vidyulata Kamath, Charles W. Hogue, Charles H. Brown

Research output: Contribution to journalArticle

2 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)507-514
Number of pages8
JournalAnesthesia and analgesia
Volume129
Issue number2
DOIs
StatePublished - Aug 1 2019

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Delirium
Observational Studies
Thoracic Surgery
Confusion
Incidence
Cognition
Linear Models
Odds Ratio
Geriatrics
Intensive Care Units

All Science Journal Classification (ASJC) codes

  • Anesthesiology and Pain Medicine

Cite this

Nomura, Yohei ; Nakano, Mitsunori ; Bush, Brian ; Tian, Jing ; Yamaguchi, Atsushi ; Walston, Jeremy ; Hasan, Rani ; Zehr, Kenton ; Mandal, Kaushik ; LaFlam, Andrew ; Neufeld, Karin J. ; Kamath, Vidyulata ; Hogue, Charles W. ; Brown, Charles H. / Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change. In: Anesthesia and analgesia. 2019 ; Vol. 129, No. 2. pp. 507-514.
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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.",
author = "Yohei Nomura and Mitsunori Nakano and Brian Bush and Jing Tian and Atsushi Yamaguchi and Jeremy Walston and Rani Hasan and Kenton Zehr and Kaushik Mandal and Andrew LaFlam and Neufeld, {Karin J.} and Vidyulata Kamath and Hogue, {Charles W.} and Brown, {Charles H.}",
year = "2019",
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doi = "10.1213/ANE.0000000000003967",
language = "English (US)",
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pages = "507--514",
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Nomura, Y, Nakano, M, Bush, B, Tian, J, Yamaguchi, A, Walston, J, Hasan, R, Zehr, K, Mandal, K, LaFlam, A, Neufeld, KJ, Kamath, V, Hogue, CW & Brown, CH 2019, 'Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change', Anesthesia and analgesia, vol. 129, no. 2, pp. 507-514. https://doi.org/10.1213/ANE.0000000000003967

Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change. / Nomura, Yohei; Nakano, Mitsunori; Bush, Brian; Tian, Jing; Yamaguchi, Atsushi; Walston, Jeremy; Hasan, Rani; Zehr, Kenton; Mandal, Kaushik; LaFlam, Andrew; Neufeld, Karin J.; Kamath, Vidyulata; Hogue, Charles W.; Brown, Charles H.

In: Anesthesia and analgesia, Vol. 129, No. 2, 01.08.2019, p. 507-514.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Observational Study Examining the Association of Baseline Frailty and Postcardiac Surgery Delirium and Cognitive Change

AU - Nomura, Yohei

AU - Nakano, Mitsunori

AU - Bush, Brian

AU - Tian, Jing

AU - Yamaguchi, Atsushi

AU - Walston, Jeremy

AU - Hasan, Rani

AU - Zehr, Kenton

AU - Mandal, Kaushik

AU - LaFlam, Andrew

AU - Neufeld, Karin J.

AU - Kamath, Vidyulata

AU - Hogue, Charles W.

AU - Brown, Charles H.

PY - 2019/8/1

Y1 - 2019/8/1

N2 - 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.

AB - 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.

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