Purpose: This study was conducted to determine characteristics associated with continued cigarette use in frail older adults and to examine how smoking history relates to current psychiatric, cognitive, and occupational functioning. Methods: Archival records were gathered for 1,064 patients (69% women) who entered On Lok SeniorHealth Services between January 1996 and December 2000. Participants were interviewed on program entry and assessed for smoking history, depressive symptoms, affective disorders, cognitive functioning, alcohol use, and physical functioning (activities of daily living [ADLs] and instrumental ADLs). Cross-sectional analyses were conducted to examine functioning at enrollment relative to smoking history. Results: Smoking history was related to age at program entry, with current smokers entering On Lok at an earlier age than former or never smokers. Current smokers were more likely to be male, to be of Caucasian or African American descent, to consume alcohol on a regular basis, and to be more independent on ADLs. Specifically, they were more independent on tasks related to their capacity to procure cigarettes or continue smoking, including shopping, using transportation, managing money, dressing themselves, and walking. Smoking history was related to depression, with symptoms lower for current and former smokers. Conclusions: Current smokers present for services at an earlier age and have higher levels of independence on ADLs instrumental to nicotine use. Data indicate characteristics associated with continued smoking and provide a foundation for targeting older individuals for cessation efforts.
Falls after elective inpatient surgical procedures are common and have physical, emotional, and financial consequences. Close interactions between patients and health care teams before and after surgical procedures may offer opportunities to address modifiable risk factors associated with falls.
Objective
To assess whether a multicomponent intervention that incorporates education, home medication review, and home safety assessment is associated with reductions in the incidence of falls after elective inpatient surgical procedures.
Design, Setting, and Participants
This prospective propensity score–matched cohort study was a prespecified secondary analysis of data from the Electroencephalography Guidance of Anesthesia to Alleviate Geriatric Syndromes (ENGAGES) randomized clinical trial, which was conducted at a single academic medical center between January 16, 2015, and May 7, 2018. Patients in the intervention group of the present study were enrolled in either arm of the ENGAGES clinical trial. Patients in the control group were selected from the Systematic Assessment and Targeted Improvement of Services Following Yearly Surgical Outcomes Surveys prospective observational cohort study, which created a registry of patient-reported postoperative outcomes at the same single center. The propensity score–matched cohort in the present study included 1396 patients (698 pairs) selected from a pool of 2013 eligible patients. All patients underwent elective surgical procedures with general anesthesia and had a hospital stay of 2 or more days. Data were analyzed from January 2, 2020, to January 11, 2022.
Interventions
The multicomponent safety intervention (offered to all patients in the ENGAGES clinical trial) included patient education on fall prevention techniques, home medication review by a geriatric psychiatrist (with communication of recommended changes to the surgeon), a self-administered home safety assessment, and targeted occupational therapy home visits with home hazard removal (offered to patients with a preoperative history of falls).
Main Outcomes and Measures
The primary outcome was patient-reported falls within 1 year after an elective inpatient surgical procedure. The secondary outcome was quality of life 1 year after an elective surgical procedure, which was measured using the physical and mental composite summary scores on the Veterans RAND 12-item health survey (score range, 0-100 points, with 0 indicating lowest quality of life and 100 indicating highest quality of life).
Results
Among 1396 patients, the median age was 69 years (IQR, 64-75 years), and 739 patients (52.9%) were male. With regard to race, 5 patients (0.4%) were Asian, 97 (6.9%) were Black or African American, 2 (0.1%) were Native Hawaiian or Pacific Islander, 1237 (88.6%) were White, 3 (0.2%) were of other race, and 52 (3.7%) were of unknown race; with regard to ethnicity, 12 patients (0.9%) were Hispanic or Latino, 1335 (95.6%) were non-Hispanic or non-Latino, and 49 (3.5%) were of unknown ethnicity. Adherence to individual intervention components was modest (from 22.9% for completion of the self-administered home safety assessment to 28.2% for implementation of the geriatric psychiatrist's recommended medication changes). Falls within 1 year after surgical procedures were reported by 228 of 698 patients (32.7%) in the intervention group and 225 of 698 patients (32.2%) in the control group. No significant difference was found in falls between the 2 groups (standardized risk difference, 0.4%; 95% CI, −4.5% to 5.3%). After adjusting for preoperative quality of life, patients in the intervention group had higher physical composite summary scores (3.8 points; 95% CI, 2.4-5.1 points) and higher mental composite summary scores (5.7 points; 95% CI, 4.7-6.7 points) at 1 year compared with patients in the control group.
Conclusions and Relevance
In this cohort study, a multicomponent safety intervention was not associated with reductions in falls within the first year after an elective surgical procedure; however, an increase in quality of life at 1 year was observed. These results suggest a need for other interventions, such as those designed to increase adherence, to lower the incidence of falls after surgical procedures.
OBJECTIVES To measure the burden of delirium in older adults with or without Alzheimer disease or related disorders (ADRDs). DESIGN Prospective, observational cohort. SETTING Inpatient hospital and study participants' homes. PARTICIPANTS A subset (n = 267) of older medical and surgical patients and their caregivers enrolled in the Better Assessment of Illness study. MEASUREMENTS Delirium burden was measured using the DEL‐B instrument (range = 0‐40, with higher scores indicating greater burden) in caregivers (DEL‐B‐C) and patients 1 month after hospitalization. Severity of cognitive impairment (Montreal Cognitive Assessment [MoCA]), delirium presence (Confusion Assessment Method [CAM]), and delirium severity (CAM‐Severity [CAM‐S]) were measured during hospitalization and at 1‐month follow‐up. ADRD diagnosis was determined by a clinical consensus process. RESULTS For patients with (n = 56) and without (n = 211) ADRD, both DEL‐B instruments had good internal consistency. DEL‐B‐C scores had a median (interquartile range) among caregivers of patients with and without ADRD of 9 (5‐15) and 5 (1‐11), respectively ( P < .05). If the patient developed delirium, caregivers experienced greater burden (β[delirium × ADRD] = −.29; P = .42), regardless of ADRD status. Further, caregiver burden was modestly correlated with patient MoCA scores (Spearman correlation coefficient, ρ = −0.18; P = .01). Patients with ADRD who developed delirium self‐reported less burden than those without ADRD (β[delirium × ADRD] = −.67; P = .044). As with caregivers, delirium burden was modestly correlated with patient MoCA score (ρ = −0.18; P = .005) and correlated with the CAM‐S in patients without ADRD (ρ = 0.38; P < .001) but not for patients with ADRD (ρ = −0.07; P = .61). CONCLUSIONS Delirium resulted in the same degree of increased caregiver burden regardless of whether a patient had ADRD, signifying delirium is equally stressful to caregivers, even among those with experience caring for someone with a chronic cognitive disorder. Delirium burden is only modestly associated with degree of cognitive impairment, suggesting that other aspects of delirium contribute to burden. J Am Geriatr Soc 67:2587–2592, 2019
Postoperative delirium has been linked to long-term cognitive decline in older adults, but this area remains under-explored. We examined pre-surgical factors in risk groups (demographic, lifestyle, cognitive/physical/sensory/mental function, frailty, medical factors, biomarkers) associated with long-term cognitive decline among 134 SAGES participants who developed delirium. Using multivariable approaches, we identified explanatory factors that accounted for variability in rates of cognitive decline in an overall model incorporating factors across groups. Baseline General Cognitive Performance (GCP) score (composite score incorporating 9 neuropsychological tests) explained the most variation in cognitive decline (10.0%), and 6 factors—lower GCP, impaired IQCODE, living alone, slow walking, less exhaustion, and orthopedic surgery—combined to explain 25% of variation in cognitive decline. Thus, pre-surgical factors predict long-term cognitive decline following delirium, with the predictive value comparing favorably to prior studies. Such predictive models will be critical to target high risk older surgical patients for preventive and therapeutic approaches.
Surgery is increasingly common in older adults. Mild cognitive impairment (MCI) and delirium, the most common surgical complication in older adults, are both associated with post-operative cognitive decline. Our study objective was to determine if patients with both delirium and MCI have the greatest post-operative cognitive decline compared to patients with only MCI, only delirium, or neither condition. The Successful Aging after Elective Surgery (SAGES) cohort (N=560) includes older adults (≥70 years) without dementia who underwent scheduled elective surgery. MCI was defined (as previously) by a pre-operative Modified Mini-Mental State Examination score ≤80 if education ≤8 years and ≤88 if education ≥9 years. Delirium was evaluated each postoperative day using the Confusion Assessment Method supplemented by medical chart review. Cognitive data was collected by a detailed neuropsychological battery administered at baseline; months 1, 2, and 6; and every 6 months thereafter. Cognitive outcomes included a General Cognitive Performance (GCP) measure and three z-score composites for executive function, language/semantic memory, and episodic memory. We used linear mixed effects models to examine cognitive decline from months 2-36, controlling for age, sex, and education. We compared cognitive slopes between patients with both MCI and delirium (MCI+/delirium+), MCI only (MCI+/delirium), or delirium only (MCI-/delirium+) to patients with neither MCI nor delirium (MCI-/delirium-). 366 (65%) were MCI-/Delirium-, 60 (11%) were MCI+/Delirium-, 95 (17%) were MCI-/Delirium+, and 39 (7%) were MCI+/Delirium+. The MCI+/Delirium+ group had the greatest difference in cognitive slopes (b) compared to the MCI-/Delirium- group (p<.001, Figures 1-3 for GCP (b = -1.06), executive function (b = -0.11), and language/semantic memory (b = -0.09). In contrast, only MCI-/Del+ showed significantly greater decline in episodic memory compared to MCI-/Delirium- (b = -0.07, p=.005; Figure 4). Additional slopes and group comparisons are provided in Table 1. General Cognitive Performance (GCP): Patients with MCI only (MCI+/Delirium-, green), Delirium only (MCI-/Delirium+, red), or both (MCI+/Delirium+, orange) exhibited greater decline in GCP than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with both MCI and Delirium declined the most. Note: Although patients were also evaluated preoperatively and at 1 month post-surgery, these time points were not analyzed in order to account for the strongest practice/retest effects commonly observed between the first 2-3 administrations. Executive Function Z-Score Cognitive Composite: Patients with MCI only (MCI+/Delirium-, green), Delirium only (MCI-/Delirium+, red), or both (MCI+/Delirium+, orange) exhibited greater decline in Executive Function than patients with neither MCI nor Delirium (MCI /Delirium, blue). Patients with both MCI and Delirium declined the most. Cognitive tests included in the composite: Trail Making Test Part B, Digit Symbol, Visual Search and Attention Task, Digit Span. Language/Semantic Memory Z-Score Cognitive Composite: Only patients with both MCI and delirium (MCI+/Delirium+, orange) exhibited greater decline in Episodic Memory than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with Delirium only (MCI- /Delirium+, red) or MCI only (MCI+/Delirium-, green) were not statistically different from patients with neither MCI nor Delirium. Cognitive tests included in the composite: Category Fluency, Boston Naming Test, F-A-S Fluency. Episodic Memory Z-Score Cognitive Composite: Only patients Delirium only (MCI- /Delirium+, red) exhibited greater decline in Episodic Memory than patients with neither MCI nor Delirium (MCI-/Delirium, blue). Patients with MCI only (MCI+/Delirium-, green) or both (MCI+/Delirium+, orange) were not statistically different from patients with neither MCI nor Delirium. Cognitive tests included in the composite: Hopkins Verbal Learning Test delayed and total. The greatest post-operative cognitive decline was observed in MCI patients who also developed post-operative delirium, suggesting that surgical patients with MCI may benefit most from known delirium prevention strategies. Greater recognition of both conditions, targeted delirium prevention, and development of interventions targeting the specific cognitive domains most affected could lessen the degree of post-operative cognitive decline in older surgical patients.
