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Cognitive Trajectories after Postoperative Delirium

Cognitive Trajectories after Postoperative Delirium. Meredith Cook – PharmD Candidate Mercer University COPHS August, 2012. Relevance. Many patients do not return to their preoperative level of cognition within 3 months of cardiac surgery. Risk factors

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Cognitive Trajectories after Postoperative Delirium

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  1. Cognitive Trajectories after Postoperative Delirium Meredith Cook – PharmD Candidate Mercer University COPHS August, 2012

  2. Relevance • Many patients do not return to their preoperative level of cognition within 3 months of cardiac surgery. • Risk factors • Older age, lower education level, presence of 1 or more coexisting conditions • Delirium affects up to ¾ of patients following cardiac surgery • Associated with adverse outcomes (functional decline, increased healthcare costs, and/or death)

  3. Rationale/Methods • Conducted by Saczynski, J.S., et al. at two academic medical centers and one VA hospital • Inclusion criteria: 60 years of age or older who were planning to undergo CABG or valve replacement • Patients follow up to 1 year post-op • Funded by: Harvard Older Americans Independence Center and others

  4. Rationale/Methods • Preoperative Assessment • Demographics, behavioral factors, functional ability (Katz Index of Independence in ADLs) coexisting conditions, and cognitive function (MMSE) • Postoperative Assessment • Began on post-op day 2 and continuing daily until discharge (MMSE, digit-span test, CAM, and Delirium Symptom Interview) • After discharge, patients were interviewed in person at 1, 6, and 12 months

  5. Rationale/Methods • 24.4% of the daily delirium assessments were missing (due to staff or patient unavailability – ie: weekend staffing) • The missing assessments did not differ significantly between patients who had delirium and those who did not • All patients underwent at least 1 delirium assessment on post-op day 2 or 3 • Charlson co-morbidity index was also calculated

  6. Statistical Analysis • Baseline characteristics – chi-square test for categorical variables and analysis of variance for continuous variables • MMSE scores over time – hierarchical linear regression model • MMSE scores were adjusted for age, educational level, sex, race/ethnic group, score on Charlsoncomorbidity index, presence or absence of stroke or TIA, surgery type, and hospital

  7. Statistical Analysis • Sensitivity Analyses • Baseline differences in MMSE scores according to delirium status • Duration of delirium • Excluded 7 patients who had a stroke postoperatively

  8. Results • 225 patients • Average age: 73 +6.7 (range: 60-90) • ¼ female • Most were white, non-Hispanic

  9. Results • Postoperative delirium developed in 46% of patients • Lasted 1-2 days in 65%; 3 or more days in 35% • Delirium patients were significantly older, less educated, more likely to be women, and less likely to be white • Also more likely to have a history of stroke or TIA and a higher average score on the Charlson co-morbidity index and lower level of preoperative cognitive function

  10. Results: Cognitive Function Scores • Avg. MMSE before surgery: 26.9 • Postoperative day 2: -4.6 points (p<0.001) • Postoperative days 3-5: +1 point (p<0.001) • Improvement slowed considerably from day 6 – day 183 • No significant improvement from day 183 – day 365

  11. Results: Cognitive Trajectories According To Delirium Status • Post-op delirium patients had significantly lower MMSE scores pre-operatively than those without delirium (25.8 vs. 26.9, p<0.001) • Greater decline in cognitive function immediately following surgery in those who developed delirium (-7.7 points vs. -2.1 points, p<0.001)

  12. Results: Cognitive Trajectories According To Delirium Status • No delirium – returned to baseline ~1 month postoperatively • With delirium – had NOT returned to baseline by 1 year postoperatively

  13. Sensitivity Analysis • Longer duration of delirium was associated with a more significant drop in MMSE score immediately following surgery and slower recovery in the 1 year post-op period • (> 3 days vs. < 3 days) • These results were similar when patients were excluded who had a stroke post-op and when MMSE scores were ranked to address non-normal distribution (no data was given in the study)

  14. Discussion • Delirium after cardiac surgery is associated with an initial decline in cognitive function, followed by an extended period of impairment • After MMSE adjustment for baseline characteristics, the average MMSE scores did not differ significantly in patients with and those without delirium at 6 months and 1 year post-op

  15. Discussion • Delirium may have long-term effects on cognitive function following cardiac surgery • Post-op delirium associated with prolonged cognitive dysfunction? • Clinically significant – risk of delirium can be predicted pre-op (delirium is preventable)

  16. My Conclusions • Does risk outweigh benefits? • Educate patients on possible risk of decline in cognitive function • Thoroughly test before surgery to assess pre-op cognitive abilities • Identify high-risk patients

  17. References • Saczynksi, Jane S. Cognitive Trajectories after Postoeprative Delirium. NEJM. July 5, 2012; 367:30-9.

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