Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation

et al. 2020

Preprint

Objectives: To determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR).Methods: Patients (N=93) aged 70 years and older, undergoing transcatheter (TAVR, N=66) or surgical (SAVR, N=27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR.Results: Delirium occurred in 21 (22.6%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66=20%) than SAVR (8/27=30%) patients, but this difference was not statistically significant (p=.298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0±3.0 vs 28.0±3.0, p=.029), lower performance in IADL (7.0 vs 8.0, p=.038), and higher STS risk scores (4.7±2.7 vs 2.9±2.3, p=.020). In multivariate analyses, patients with intermediate (score>3 to ≤8) and high (score>8) STS risk scores had 4.3 (95%CI 1.2-15.1, p=.025) and 16.5 (95%CI 2.0-138.2, p=.010), respectively, higher odds of incident delirium compared to patients with low (score≤3) STS risk scores. At 3-month follow-up (N=77), patients with delirium still had lower MMSE score (27.0±8.0 vs 28.0±2.0, p=.007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [-3.03-0.80], p=.248).Conclusions: Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions.

Section: Discussionsupporting

confidence: 87%

Section: Discussionsupporting

confidence: 83%

Delirium in older patients undergoing aortic valve replacement: Incidence, predictors, and cognitive prognosis.

et al. 2020

Preprint

“…Thus, even though this score was not intended to identify patients at risk for delirium, it gathers extended information about a patient health (hypertension, diabetes, chronic lung disease, renal failure) that likely also re ects his or her potential vulnerability to develop postoperative complications, including delirium. These results extends those of previous studies that showed a signi cant association between frailty and postoperative delirium in TAVI (22,51) as well as other types of surgery (52)(53)(54). Thus, STS risk score could certainly be considered as a proxy measure of frailty in older patients who are candidate for AVR.…”

Section: Discussionsupporting

confidence: 87%

“…This nding is even more striking when considering that all TAVR patients, at the time of the study, underwent general anesthesia, a possible additional risk factor for delirium. (51,55) Results also strengthen previous evidence in showing that, among patients' baseline characteristics, cognitive performance was a strong independent predictor of postoperative delirium. In contrast, performance in Instrumental ADL did not remain an independent predictor of delirium once adjusting for patients' cognitive performance at baseline and the type of AVR.…”

Section: Discussionsupporting

confidence: 83%

Delirium in older patients undergoing aortic valve replacement Incidence, predictors, and cognitive prognosis.

et al. 2020

Preprint

Background: Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR).Methods: Patients (N=93) aged 70 years and older, undergoing transcatheter (TAVR, N=66) or surgical (SAVR, N=27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR.Results: Delirium occurred in 21 (22.6%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66=20%) than SAVR (8/27=30%) patients, but this difference was not statistically significant (p=.298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0±3.0 vs 28.0±3.0, p=.029), lower performance in IADL (7.0 vs 8.0, p=.038), and higher STS risk scores (4.7±2.7 vs 2.9±2.3, p=.020). In multivariate analyses, patients with intermediate (score>3 to ≤8) and high (score>8) STS risk scores had 4.3 (95%CI 1.2-15.1, p=.025) and 16.5 (95%CI 2.0-138.2, p=.010), respectively, higher odds of incident delirium compared to patients with low (score≤3) STS risk scores. At 3-month follow-up (N=77), patients with delirium still had lower MMSE score (27.0±8.0 vs 28.0±2.0, p=.007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [-3.03-0.80], p=.248). Conclusions: Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions.

“…This nding is even more striking when considering that all TAVR patients, at the time of the study, underwent general anesthesia, a possible additional risk factor for delirium. (49,50) Results also strengthen previous evidence in showing that, among patients' baseline characteristics, cognitive performance was a strong independent predictor of postoperative delirium. In contrast, performance in Instrumental ADL did not remain an independent predictor of delirium once adjusting for patients' cognitive performance at baseline and the type of AVR.…”

Section: Discussionsupporting

confidence: 82%

Delirium in older patients undergoing aortic valve replacement Incidence, predictors, and cognitive prognosis

et al. 2020

Preprint

Background: To determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR).Methods: Patients (N=93) aged 70 years and older, undergoing transcatheter (TAVR, N=66) or surgical (SAVR, N=27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR.Results: Delirium occurred in 21 (22.6%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66=20%) than SAVR (8/27=30%) patients, but this difference was not statistically significant (p=.298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0±3.0 vs 28.0±3.0, p=.029), lower performance in IADL (7.0 vs 8.0, p=.038), and higher STS risk scores (4.7±2.7 vs 2.9±2.3, p=.020). In multivariate analyses, patients with intermediate (score>3 to ≤8) and high (score>8) STS scores had 4.3 (95%CI 1.2-15.1, p=.025) and 16.5 (95%CI 2.0-138.2, p=.010), respectively, higher odds of incident delirium compared to patients with low (score≤3) STS scores. At 3-month follow-up (N=77), patients with delirium still had lower MMSE score (27.0±8.0 vs 28.0±2.0, p=.007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [-3.03-0.80], p=.248).Conclusions: Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS score could enhance the identification of high-risk older patients to better target preventative interventions.