Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

Lina Chen; Emily Au; Aparna Saripella; Paras Kapoor; Ellene Yan; Jean Wong; David F Tang-Wai; David Gold; Sheila Riazi; Colin Suen; David He; Marina Englesakis; Mahesh Nagappa; Frances Chung

doi:10.1016/j.jclinane.2022.110883

Postoperative outcomes in older surgical patients with preoperative cognitive impairment: A systematic review and meta-analysis

J Clin Anesth. 2022 Sep:80:110883. doi: 10.1016/j.jclinane.2022.110883. Epub 2022 May 24.

Authors

Lina Chen¹, Emily Au¹, Aparna Saripella¹, Paras Kapoor¹, Ellene Yan¹, Jean Wong², David F Tang-Wai³, David Gold⁴, Sheila Riazi¹, Colin Suen¹, David He⁵, Marina Englesakis⁶, Mahesh Nagappa⁷, Frances Chung⁸

Affiliations

¹ Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada.
² Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, ON, Canada.
³ Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada.
⁴ Department of Psychiatry, Krembil Brain Institute, University of Toronto, Toronto, ON, Canada.
⁵ Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada.
⁶ Library & Information Services, University Health Network, Toronto, ON, Canada.
⁷ Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
⁸ Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada. Electronic address: frances.chung@uhn.ca.

PMID: 35623265
DOI: 10.1016/j.jclinane.2022.110883

Abstract

Study objective: To determine the effect of cognitive impairment (CI) and dementia on adverse outcomes in older surgical patients.

Design: A systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs). Various databases were searched from their inception dates to March 8, 2021.

Setting: Preoperative assessment.

Patients: Older patients (≥ 60 years) undergoing non-cardiac surgery.

Measurements: Outcomes included postoperative delirium, mortality, discharge to assisted care, 30-day readmissions, postoperative complications, and length of hospital stay. Effect sizes were calculated as Odds Ratio (OR) and Mean Difference (MD) based on random effect model analysis. The quality of included studies was assessed using the Cochrane Risk Bias Tool for RCTs and Newcastle-Ottawa Scale for observational cohort studies.

Results: Fifty-three studies (196,491 patients) were included. Preoperative CI was associated with a significant risk of delirium in older patients after non-cardiac surgery (25.1% vs. 10.3%; OR: 3.84; 95%CI: 2.35, 6.26; I²: 76%; p < 0.00001). Cognitive impairment (26.2% vs. 13.2%; OR: 2.28; 95%CI: 1.39, 3.74; I²: 73%; p = 0.001) and dementia (41.6% vs. 25.5%; OR: 1.96; 95%CI: 1.34, 2.88; I²: 99%; p = 0.0006) significantly increased risk for 1-year mortality. In patients with CI, there was an increased risk of discharge to assisted care (44.7% vs. 38.3%; OR 1.74; 95%CI: 1.05, 2.89, p = 0.03), 30-day readmissions (14.3% vs. 10.8%; OR: 1.36; 95%CI: 1.00, 1.84, p = 0.05), and postoperative complications (40.7% vs. 18.8%; OR: 1.85; 95%CI: 1.37, 2.49; p < 0.0001).

Conclusions: Preoperative CI in older surgical patients significantly increases risk of delirium, 1-year mortality, discharge to assisted care, 30-day readmission, and postoperative complications. Dementia increases the risk of 1-year mortality. Cognitive screening in the preoperative assessment for older surgical patients may be helpful for risk stratification so that appropriate management can be implemented to mitigate adverse postoperative outcomes.

Keywords: Cognitive impairment; Delirium; Dementia; Older adults; Postoperative complications; Surgery.

Publication types

Meta-Analysis
Review
Systematic Review
Research Support, Non-U.S. Gov't

MeSH terms

Aged
Cognitive Dysfunction* / epidemiology
Cognitive Dysfunction* / etiology
Delirium* / epidemiology
Delirium* / etiology
Delirium* / prevention & control
Dementia*
Humans
Length of Stay
Postoperative Complications / epidemiology
Postoperative Complications / etiology
Postoperative Complications / prevention & control