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

Nomura, Yohei MD*; Nakano, Mitsunori MD; Bush, Brian MD; Tian, Jing MS; Yamaguchi, Atsushi MD, PhD*; Walston, Jeremy MD, PhD§; Hasan, Rani MD, MHS; Zehr, Kenton MD; Mandal, Kaushik MD; LaFlam, Andrew BS#; Neufeld, Karin J. MD, MPH**; Kamath, Vidyulata PhD††; Hogue, Charles W. MD‡‡; Brown, Charles H. IV MD, MHS

doi: 10.1213/ANE.0000000000003967
Geriatric Anesthesia: Original Clinical Research Report
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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.

From the *Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan

Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland

§Department of Geriatrics and Gerontology

Department of Medicine

Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland

#School of Medicine, Tufts University, Medford, Massachusetts

**Department of Psychiatry and Behavioral Sciences

††Division of Medical Psychology, Johns Hopkins University School of Medicine, Baltimore, Maryland

‡‡Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Published ahead of print 29 October 2018.

Accepted for publication October 29, 2018.

Funding: This work was supported by Older Americans Independence Center Research Career Development Core Award (P30 AG021334). C.H.B. was supported by National Institutes of Health (NIH) K76 AG057020, International Anesthesia Research Society, Johns Hopkins Clinician Scientist Award, and Magic That Matters Grant. C.W.H. was supported by NIH RO1 HL092259.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

Clinical trial registration numbers: NCT00981474 and NCT02587039.

Reprints will not be available from the authors.

Address correspondence to Charles H. Brown IV, MD, MHS, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Zayed 6208, 1800 Orleans St, Baltimore, MD 21287. Address e-mail to cbrownv@jhmi.edu.

Copyright © 2018 International Anesthesia Research Society
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