Delirium in Older Patients Undergoing Aortic Valve Replacement: Incidence, Predictors, and Cognitive Prognosis

Overview

Journal BMC Geriatr

Publisher Biomed Central

Specialty Geriatrics

Date 2021 Mar 3

PMID 33653285

Citations 8

Authors

Marc Humbert

Christophe J Bula

Olivier Muller

Helene Krief

Pierre Monney

Affiliations

Soon will be listed here.

Abstract

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 (23%) 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.

Citing Articles

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Does Comprehensive Geriatric Assessment Reduce the Incidence of Postoperative Delirium? A Quasi-experimental Study in Older Adults Undergoing Transcatheter Aortic Valve Implantation.

Schwesinger A, Tsai L, Lang W, Mantegazza N, Bauernschmitt R, Wilhelm M Clin Interv Aging. 2024; 19:347-355.

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Association between Neuron-Specific Enolase, Memory Function, and Postoperative Delirium after Transfemoral Aortic Valve Replacement.

Nubel J, Buhre C, Hoffmeister M, Oess S, Labrenz O, Jost K J Cardiovasc Dev Dis. 2023; 10(11).

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Effect of pharmacist-led intervention protocol on preventing postoperative delirium after elective cardiovascular surgery.

Asai Y, Yanagawa T, Takahashi M PLoS One. 2023; 18(10):e0292786.

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Postoperative delirium in 47 379 individuals undergoing transcatheter aortic valve replacement: a systematic review and meta-analysis.

Ochani S, Adnan A, Siddiqui A, Kalwar A, Kukreja S, Ahmad M Ann Med Surg (Lond). 2023; 85(9):4476-4490.

PMID: 37663694 PMC: 10473306. DOI: 10.1097/MS9.0000000000001096.

References

Mack M, Leon M, Thourani V, Makkar R, Kodali S, Russo M . Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med. 2019; 380(18):1695-1705. DOI: 10.1056/NEJMoa1814052. View

Rouleau I, Salmon D, Butters N . Longitudinal analysis of clock drawing in Alzheimer's disease patients. Brain Cogn. 1996; 31(1):17-34. DOI: 10.1006/brcg.1996.0022. View

Knipp S, Kahlert P, Jokisch D, Schlamann M, Wendt D, Weimar C . Cognitive function after transapical aortic valve implantation: a single-centre study with 3-month follow-up. Interact Cardiovasc Thorac Surg. 2012; 16(2):116-22. PMC: 3548540. DOI: 10.1093/icvts/ivs461. View

Eide L, Ranhoff A, Fridlund B, Haaverstad R, Hufthammer K, Kuiper K . Delirium as a Predictor of Physical and Cognitive Function in Individuals Aged 80 and Older After Transcatheter Aortic Valve Implantation or Surgical Aortic Valve Replacement. J Am Geriatr Soc. 2016; 64(6):1178-86. DOI: 10.1111/jgs.14165. View

Popma J, Deeb G, Yakubov S, Mumtaz M, Gada H, OHair D . Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N Engl J Med. 2019; 380(18):1706-1715. DOI: 10.1056/NEJMoa1816885. View

Pol R, van Leeuwen B, Visser L, Izaks G, van den Dungen J, Tielliu I . Standardised frailty indicator as predictor for postoperative delirium after vascular surgery: a prospective cohort study. Eur J Vasc Endovasc Surg. 2011; 42(6):824-30. DOI: 10.1016/j.ejvs.2011.07.006. View

Maniar H, Lindman B, Escallier K, Avidan M, Novak E, Melby S . Delirium after surgical and transcatheter aortic valve replacement is associated with increased mortality. J Thorac Cardiovasc Surg. 2016; 151(3):815-823.e2. PMC: 5088104. DOI: 10.1016/j.jtcvs.2015.10.114. View

Inouye S, van Dyck C, Alessi C, Balkin S, Siegal A, Horwitz R . Clarifying confusion: the confusion assessment method. A new method for detection of delirium. Ann Intern Med. 1990; 113(12):941-8. DOI: 10.7326/0003-4819-113-12-941. View

Holmes Jr D, Brennan J, Rumsfeld J, Dai D, OBrien S, Vemulapalli S . Clinical outcomes at 1 year following transcatheter aortic valve replacement. JAMA. 2015; 313(10):1019-28. DOI: 10.1001/jama.2015.1474. View

10.

Eide L, Ranhoff A, Fridlund B, Haaverstad R, Hufthammer K, Kuiper K . Comparison of frequency, risk factors, and time course of postoperative delirium in octogenarians after transcatheter aortic valve implantation versus surgical aortic valve replacement. Am J Cardiol. 2015; 115(6):802-9. DOI: 10.1016/j.amjcard.2014.12.043. View

11.

Nashef S, Roques F, Sharples L, Nilsson J, Smith C, Goldstone A . EuroSCORE II. Eur J Cardiothorac Surg. 2012; 41(4):734-44. DOI: 10.1093/ejcts/ezs043. View

12.

Ghanem A, Kocurek J, Sinning J, Wagner M, Becker B, Vogel M . Cognitive trajectory after transcatheter aortic valve implantation. Circ Cardiovasc Interv. 2013; 6(6):615-24. DOI: 10.1161/CIRCINTERVENTIONS.112.000429. View

13.

Folstein M, Folstein S, McHugh P . "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12(3):189-98. DOI: 10.1016/0022-3956(75)90026-6. View

14.

Leon M, Smith C, Mack M, Miller D, Moses J, Svensson L . Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010; 363(17):1597-607. DOI: 10.1056/NEJMoa1008232. View

15.

Leon M, Smith C, Mack M, Makkar R, Svensson L, Kodali S . Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients. N Engl J Med. 2016; 374(17):1609-20. DOI: 10.1056/NEJMoa1514616. View

16.

Hudetz J, Iqbal Z, Gandhi S, Patterson K, Byrne A, Pagel P . Postoperative delirium and short-term cognitive dysfunction occur more frequently in patients undergoing valve surgery with or without coronary artery bypass graft surgery compared with coronary artery bypass graft surgery alone: results of a pilot.... J Cardiothorac Vasc Anesth. 2010; 25(5):811-6. DOI: 10.1053/j.jvca.2010.05.003. View

17.

Brown 4th C, Probert J, Healy R, Parish M, Nomura Y, Yamaguchi A . Cognitive Decline after Delirium in Patients Undergoing Cardiac Surgery. Anesthesiology. 2018; 129(3):406-416. PMC: 6513020. DOI: 10.1097/ALN.0000000000002253. View

18.

Katz S, Ford A, Moskowitz R, Jackson B, JAFFE M . STUDIES OF ILLNESS IN THE AGED. THE INDEX OF ADL: A STANDARDIZED MEASURE OF BIOLOGICAL AND PSYCHOSOCIAL FUNCTION. JAMA. 1963; 185:914-9. DOI: 10.1001/jama.1963.03060120024016. View

19.

Barbash I, Finkelstein A, Barsheshet A, Segev A, Steinvil A, Assali A . Outcomes of Patients at Estimated Low, Intermediate, and High Risk Undergoing Transcatheter Aortic Valve Implantation for Aortic Stenosis. Am J Cardiol. 2015; 116(12):1916-22. DOI: 10.1016/j.amjcard.2015.09.030. View

20.

Husser O, Fujita B, Hengstenberg C, Frerker C, Beckmann A, Mollmann H . Conscious Sedation Versus General Anesthesia in Transcatheter Aortic Valve Replacement: The German Aortic Valve Registry. JACC Cardiovasc Interv. 2018; 11(6):567-578. DOI: 10.1016/j.jcin.2017.12.019. View