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• W3024150653 abstract "While caring for patients, are the most vulnerable populations routinely being screened for neurocognitive disease? Despite a desire to protect these individuals, is there the evidence and guidelines that are needed? As aptly cited in the article by Tong et al., perioperatively the focus is on vital organ function, with a limited assessment of neurocognitive function and outcomes.1Tong C Huang C Wu J et al.The prevalence and impact of undiagnosed mild cognitive impairment in elderly patients undergoing thoracic surgery: A prospective cohort study.J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar Cardiac assessment involves investigations ranging from invasive and noninvasive tests to biochemical markers, providing concrete and quantifiable information on which we may act. Consistency in isolating the brain as its own vital system and assessing, optimizing, and monitoring this most important organ must not be overlooked. To date, there is still a limited pathophysiologic understanding of patients presenting with mild cognitive impairment (MCI) and the neurocognitive disruption the perioperative period may inflict on such an individual. As a result, the immediate and long-term implications of postoperative delirium (POD) and postoperative cognitive dysfunction (POCD) may be missed. In their publication, Tong et al. reported on a prospective cohort study that examined the prevalence and effect of undiagnosed MCI in elderly patients undergoing thoracic surgery. Using a cutoff of 26 on the Chinese Modified Montreal Congnitive Assessment (MoCA) test, they divided 154 patients ages 65 years or older into groups of those with and without MCI. The incidence of MCI and POD in patients older than 65 was 49% and 22%, respectively. Perhaps it is not surprising that the primary outcome of POD was found to be significantly greater in those with MCI preoperatively (odds ratio = 2.573). The authors concluded that MCI is an independent risk factor for POD. Positive secondary outcomes were limited to an increase in hospital length of stay (4 v 5 days) in those with MCI.1Tong C Huang C Wu J et al.The prevalence and impact of undiagnosed mild cognitive impairment in elderly patients undergoing thoracic surgery: A prospective cohort study.J Cardiothorac Vasc Anesth. 2020; Abstract Full Text Full Text PDF Scopus (4) Google Scholar The outcome of their study supported the previously documented finding that approximately 10% of older patients undergoing surgery develop POD and that number increases to between 30% and 65% for specific surgeries such as hip fracture, cardiac, and emergency procedures.2Rudolph JL Marcantonio ER Review articles: Postoperative delirium: Acute change with long-term implications.Anesth Analg. 2011; 112: 1202-1211Crossref PubMed Scopus (298) Google Scholar Although not discussed in the study by Tong et al., the incidence of POCD in older patients has been reported to be up to 25% at 1 week postoperatively and up to 10% in patients undergoing noncardiac surgery at 3 months.3Inouye SK Marcantonio ER Kosar CM et al.The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients.Alzheimers Dement. 2016; 12: 766-775Abstract Full Text Full Text PDF PubMed Scopus (182) Google Scholar These numbers are relevant to our aging population; in the United States alone it is anticipated that by the year 2030, 70 million citizens will be older than 65.4Yancik R Population aging and cancer: A cross-national concern.Cancer J. 2005; 1: 437-441Crossref Scopus (270) Google Scholar Of these patients, cancer remains the leading cause of death for those between 60 and 79 years old, with the median age of patients presenting for surgical resection of lung cancer to be older than 70.5Jemal A Siegel R Ward E et al.Cancer statistics, 2009.CA Cancer J Clin. 2009; 59: 225-249Crossref PubMed Scopus (9775) Google Scholar The conclusions of their study should further prompt clinicians to remain vigilant regarding the neurocognitive status of their patients throughout the entire perioperative period. It is not clear whether POD and POCD are 2 manifestations of the same underlying spectrum of neurocognitive disease or completely separate entities because there are no routine biological markers for either condition. Both deserve attention because there are certain overlaps, including risks factors and a tendency for patients with POD to have worse postoperative cognitive trajectories than those without POD in the months after surgery.6Berger M Terrando N Smith SK et al.Neurocognitive function after cardiac surgery: From phenotypes to mechanisms.Anesthesiology. 2018; 129: 829-851Crossref PubMed Scopus (80) Google Scholar Some studies have noted worse POCD up to 1 year after surgery in patients who developed POD.7Saczynski JS Marcantonio ER Quach L et al.Cognitive trajectories after postoperative delirium.N Engl J Med. 2012; 367: 30-39Crossref PubMed Scopus (639) Google Scholar As noted by Devinney et al., discrepancy remains among findings in the literature, which may be the consequence of differing cognitive assessment tools and the difficulty in obtaining sufficient power and follow-up in large studies.8Devinney MJ Mathew JP Berger M Postoperative delirium and postoperative cognitive dysfunction: Two sides of the same coin?.Anesthesiology. 2018; 129: 389-391Crossref PubMed Scopus (14) Google Scholar With these facts in mind, POCD was not explored in the study by Tong et al. but remains a highly relevant issue for their patient population. Although not an identified outcome of their study, Tong et al. used a multivariate logistic regression analysis to show that a duration of surgery longer than 80 minutes and segmentectomy/lobectomy resection versus wedge resection both may contribute to POD. Patients who developed delirium also had a higher risk of postoperative pulmonary complications, including atelectasis, pulmonary infection, and respiratory failure. These trends in the data and the primary outcome revealing greater rates of POD in those with MCI were in keeping with previously published data and what might be expected in the vulnerable, elderly thoracic patient population. While the etiology of POD is multifactorial, studies have attempted to characterize optimal care or pharmacologic therapy to mitigate the risk. Exposure to anesthesia and modulation of depth of anesthesia have been hypothesized as potential methods of decreasing the risk of POD. A randomized clinical trial, the Effect of Electroencephalography-Guided Anesthetic Administration on Postoperative Delirium Among Older Adults Undergoing Major Surgery (ENGAGES), examined the use of electroencephalography-guided anesthetic administration and the potential for decreasing POD in older patients undergoing major surgery. The avoidance of burst suppression and excessively deep anesthesia did not decrease the incidence of POD.9Wilders TS Mickle AM Abdallah AB et al.Effect of electroencephalography-guided anesthetic administration on postoperative delirium among older adults undergoing major surgery: The ENGAGES randomized clinical trial.JAMA. 2019; 321: 473-483Crossref PubMed Scopus (160) Google Scholar Dexmedetomidine, an alpha 2 adrenergic agonist, has shown some degree of promise in animal models and intensive care units. However, a randomized clinical trial published by Deiner et al. found no improvement in the rates of POD using an intraoperative infusion of dexmedetomidine.10Deiner S Luo X Lin HM et al.Intraoperative infusion of dexmedetomidine for prevention of postoperative delirium and cognitive dysfunction in elderly patients undergoing major elective noncardiac surgery: A randomized clinical trial.JAMA Surg. 2017; 152: e171505Crossref PubMed Scopus (135) Google Scholar It is clear that the older, more vulnerable brain could be best protected through multiple evidence-based interventions implemented throughout the perioperative period, although what this would entail remains unclear. Enhanced recovery after surgery protocols offer the opportunity for a multidisciplinary approach to the care of the surgical patient. Evidence-based care elements that support the recovery of the patient are particularly important in those who are elderly with the increased risk of MCI, POD, and POCD. Guidelines for the enhanced recovery after lung surgery were published in 2019 by the Enhanced Recovery After Surgery Society and the European Society of Thoracic Surgery. They strongly recommended avoiding the use of preoperative short- and long-acting benzodiazepines, citing increased risk of delirium and decreased postoperative cognitive function (based on moderate evidence).11Batchelor TJP Rasburn NJ Abdelnour-Berchtold E et al.Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS).Eur J Cardiothorac Surg. 2019; 55: 91-115Crossref PubMed Scopus (307) Google Scholar However, evidence-based recommendations relating to minimizing POD and POCD remain limited. The work of Tong et al. provides a reminder that the perioperative management of patients must include a focus on neurocognition. The subtle presentation of MCI can be overlooked easily but will have significant consequences for the aging thoracic patient population. Clinicians have yet to obtain a thorough understanding of the pathophysiology of MCI, POD, and POCD and seems far from the diagnostic aid of routine biomarkers. Performing and implementing high-quality research remains imperative. The author have no conflict of interest. The Prevalence and Impact of Undiagnosed Mild Cognitive Impairment in Elderly Patients Undergoing Thoracic Surgery: A Prospective Cohort StudyJournal of Cardiothoracic and Vascular AnesthesiaVol. 34Issue 9PreviewThe objective of this study was to explore the prevalence of undiagnosed mild cognitive impairment (MCI) and its association with adverse outcomes in elderly patients undergoing thoracic surgery. Full-Text PDF" @default.
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• W3024150653 title "Seventy Is the New Fifty: But What Happens After Thoracic Surgery?" @default.
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