Cognitive decline in the middle‐aged after surgery and anaesthesia: results from the Wisconsin Registry for Alzheimer's Prevention cohort

Surgery and anaesthesia might affect cognition in middle‐aged people without existing cognitive dysfunction. We measured memory and executive function in 964 participants, mean age 54 years, and again four years later, by when 312 participants had had surgery and 652 participants had not. Surgery between tests was associated with a decline in immediate memory by one point (out of a maximum of 30), p = 0.013: memory became abnormal in 77 out of 670 participants with initially normal memory, 21 out of 114 (18%) of whom had had surgery compared with 56 out of 556 (10%) of those who had not, p = 0.02. The number of operations was associated with a reduction in immediate memory on retesting, beta coefficient (SE) 0.08 (0.03), p = 0.012. Working memory decline was also associated with longer cumulative operations, beta coefficient (SE) ?0.01 (0.00), p = 0.028. A reduction in cognitive speed and flexibility was associated with worse ASA physical status, beta coefficient (SE) 0.55 (0.22) and 0.37 (0.17) for ASA 1 and 2 vs. 3, p = 0.035. However, a decline in working memory was associated with better ASA physical status, beta coefficient (SE) ?0.48 (0.21) for ASA 1 vs. 3, p = 0.01.     

Chronic kidney disease and cognitive impairment in the elderly: the health, aging, and body composition study

Previous studies suggest a link between chronic kidney disease (CKD) and cognitive impairment. Whether the longitudinal course of cognitive impairment differs among people with or without CKD is unknown. Data collected in 3034 elderly individuals who participated in the Health, Aging, and Body Composition study were analyzed. Cognitive function was assessed with the Modified Mini-Mental State Exam (3MS) at baseline and then 2 and 4 yr after baseline. Cognitive impairment was defined as a 3MS score <80 or a decline in 3MS >5 points after 2 or 4 yr of follow-up among participants with baseline 3MS scores > or =80. Participants with CKD, defined as an estimated GFR (eGFR) <60 ml/min per 1.73 m2, were further divided into two eGFR strata. Unadjusted mean baseline 3MS scores and mean declines in 3MS scores over 4 yr were significantly more pronounced for participants with lower baseline eGFR. More advanced stages of CKD were associated with an increased risk for cognitive impairment: Odds ratio (OR) 1.32 (95% confidence interval [CI] 1.03 to 1.69) and OR 2.43 (95% CI, 1.38 to 4.29) for eGFR 45 to 59 ml/min per 1.73 m2 and <45 ml/min per 1.73 m2, respectively, adjusted for case mix, baseline 3MS scores, and other potential confounders. CKD is associated with an increased risk for cognitive impairment in the elderly that cannot be fully explained by other well-established risk factors. Studies aimed at understanding the mechanism(s) responsible for cognitive impairment in CKD and efforts to interrupt this decline are warranted.     

Preexisting cognitive impairment in women before cardiac surgery and its relationship with C-reactive protein concentrations

Preoperative cognitive state is seldom considered when investigating the effects of cardiac surgery on cognition. In this study we sought to determine the prevalence of cognitive impairment in women scheduled for cardiac surgery using nonhospitalized volunteers as a reference group and to examine the relationship between C-reactive protein levels and cognitive impairment. Psychometric testing was performed in 108 postmenopausal women scheduled for cardiac surgery and in 58 nonhospitalized control women. High sensitivity C-reactive protein levels were measured in the surgical patients. Preoperative cognitive impairment was defined as >2 sd lower scores on > or =2 tests compared with the controls. Cognitive impairment was present in 49 of 108 (45%) patients. C-reactive protein levels were higher for patients with compared with those without cognitive impairment (median, 8.1 mg/L versus 4.7 mg/L; P = 0.04). Based on multivariate logistic regression analysis, patient age, lower attained level of education, type 2 diabetes mellitus, and prior myocardial infarction identified risk for cognitive impairment (P < 0.05) but C-reactive protein levels did not (P = 0.09). In conclusion, cognitive impairment is prevalent in women before cardiac surgery. C-reactive protein levels are increased in women with this condition but the relationship between this inflammatory marker and preexisting cognitive impairment is likely secondary to the acute phase reactant serving as a marker for other predisposing conditions.     

Gastro-oesophageal reflux related cough and its response to laparoscopic fundoplication

BACKGROUND: This study was designed to determine prospectively the rate of cough before and after laparoscopic Nissen fundoplication performed for the control of gastro-oesophageal reflux disease. METHODS: One hundred and ninety five consecutive patients (76 men) of mean (SD) age 46.9 (14.1) years with proven gastro-oesophageal reflux disease, who were either on long term omeprazole (n = 187) or who had not responded to a trial of omeprazole (n = 8), took part in the study which was carried out in a university teaching hospital that included a regional respiratory referral centre. Patients underwent oesophageal manometry, 24 hour oesophageal pH testing, and symptom score evaluation by an independent observer before and six months after laparoscopic Nissen fundoplication. RESULTS: One hundred and thirty three patients presented with reflux symptoms and 62 with respiratory symptoms; 68% of patients complained of cough before surgery (86% with respiratory symptoms, 60% with gastrointestinal symptoms). The percentage reflux time in 24 hours fell significantly (p < 0.0001) from a mean (SD) of 9.38 (10.99)% to 1.22 (2.92)%, lower oesophageal sphincter tone rose significantly (p < 0.0001) from a mean (SD) of 7.71 (5.90) mm Hg to 21.74 (10.84) mm Hg, and the cough score fell from a median value of 8.0 (IQR 12.0) to 0 (IQR 3) following surgery. Of the patients with cough, 51% were cough free after surgery and 31% improved. The patients with respiratory symptoms had a higher cough score before (median 12.0 (IQR 5.5) versus 4.0 (IQR 8.75), p < 0.0001) and after surgery (median 1 (7.5) versus 0.0 (IQR 1.0), p = 0.0045) than those with gastrointestinal symptoms. CONCLUSIONS: Patients who present to gastroenterologists with severe reflux commonly complain of cough. Laparoscopic Nissen fundoplication is effective in the control of cough in patients with gastro-oesophageal reflux disease, with or without primary respiratory disease.     

Cognitive decline is associated with an accelerated rate of bone loss and increased fracture risk in women: a prospective study from the Canadian Multicentre Osteoporosis Study

Cognitive decline and osteoporosis often coexist and some evidence suggests a causal link. However, there are no data on the longitudinal relationship between cognitive decline, bone loss and fracture risk, independent of aging. This study aimed to determine the association between: (i) cognitive decline and bone loss; and (ii) clinically significant cognitive decline (≥3 points) on Mini Mental State Examination (MMSE) over the first 5 years and subsequent fracture risk over the following 10 years. A total of 1741 women and 620 men aged ≥65 years from the population-based Canadian Multicentre Osteoporosis Study were followed from 1997 to 2013. Association between cognitive decline and (i) bone loss was estimated using mixed-effects models; and (ii) fracture risk was estimated using adjusted Cox models. Over 95% of participants had normal cognition at baseline (MMSE ≥ 24). The annual % change in MMSE was similar for both genders (women −0.33, interquartile range [IQR] −0.70 to +0.00; and men −0.34, IQR: −0.99 to 0.01). After multivariable adjustment, cognitive decline was associated with bone loss in women (6.5%; 95% confidence interval [CI], 3.2% to 9.9% for each percent decline in MMSE from baseline) but not men. Approximately 13% of participants experienced significant cognitive decline by year 5. In women, fracture risk was increased significantly (multivariable hazard ratio [HR], 1.61; 95% CI, 1.11 to 2.34). There were too few men to analyze. There was a significant association between cognitive decline and both bone loss and fracture risk, independent of aging, in women. Further studies are needed to determine mechanisms that link these common conditions. © 2021 American Society for Bone and Mineral Research (ASBMR).     

Comparison of peripheral nerve blockade characteristics between non‐diabetic patients and patients suffering from diabetic neuropathy: a prospective cohort study

Animal data have demonstrated increased block duration after local anaesthetic injections in diabetic rat models. Whether the same is true in humans is currently undefined. We, therefore, undertook this prospective cohort study to test the hypothesis that type‐2 diabetic patients suffering from diabetic peripheral neuropathy would have increased block duration after ultrasound‐guided popliteal sciatic nerve block when compared with patients without neuropathy. Thirty‐three type‐2 diabetic patients with neuropathy and 23 non‐diabetic control patients, scheduled for fore‐foot surgery, were included prospectively. All patients received an ultrasound‐guided popliteal sciatic nerve block with a 30 ml 1:1 mixture of lidocaine 1% and bupivacaine 0.5%. The primary outcome was time to first opioid request after block procedure. Secondary outcomes included the time to onset of sensory blockade, and pain score at rest on postoperative day 1 (numeric rating scale 0–10). These outcomes were analysed using an accelerated failure time regression model. Patients in the diabetic peripheral neuropathy group had significantly prolonged median (IQR [range]) time to first opioid request (diabetic peripheral neuropathy group 1440 (IQR 1140–1440 [180–1440]) min vs. control group 710 (IQR 420–1200 [150–1440] min, p = 0.0004). Diabetic peripheral neuropathy patients had a time ratio of 1.57 (95%CI 1.10–2.23, p < 0.01), experienced a 59% shorter time to onset of sensory blockade (median time ratio 0.41 (95%CI 0.28–0.59), p < 0.0001) and had lower median (IQR [range]) pain scores at rest on postoperative day 1 (diabetic peripheral neuropathy group 0 (IQR 0–1 [0–5]) vs. control group 3 (IQR 0–5 [0–9]), p = 0.001). In conclusion, after an ultrasound‐guided popliteal sciatic nerve block, patients with diabetic peripheral neuropathy demonstrated reduced time to onset of sensory blockade, with increased time to first opioid request when compared with patients without neuropathy.     

The outcome of patients on the cholecystectomy waiting list in Western Australia 1999-2005

Background: Surgeons are noticing increasing numbers of cholecystectomy waiting list patients presenting with complications of their gallstones. In this study, we analysed the outcome of these to ascertain natural history and outcome. Methods: Data for 5298 waiting list patients in Western Australia, from 1999 to 2006, were analysed. Negative binomial regression was used to analyse waiting times data with Waitlist Year, Urgency Category and Aboriginality, after adjusting for Gender, Location and Age at Cholecystectomy. Results: The overall median waiting time for surgery was 40 days (interquartile range (IQR) = 15–103). The median waiting times for Urgent, Semi‐Urgent, and Routine categories were 21 (IQR = 8–63), 44 (IQR = 20–97) and 50 (IQR = 17–131) days, respectively. While waiting for surgery, 240 (5%) patients had gallstone‐related admissions. Eighty (33.3%) patients had previous gallstone‐related admissions prior to their enrolment on the waiting list. Analysis of the crude odds ratio showed that the probability of readmission during wait for surgery was three times more, when the surgery was not performed within the recommended time. Aboriginal and Torres Strait Islanders wait 1.77 times longer than non aboriginals (P < 0.001) and waiting time decreased with more recent calendar years. (P= 0.001) Patients in the metropolitan hospitals waited twice as long compared with the regional hospitals (P < 0.001). Conclusion: Approximately 5% of patients on the waiting list for an elective cholecystectomy were readmitted to the hospital for gallstone‐related problems. Proper categorization of patients and definitive surgical treatment of acute gallbladder disease at index presentation might decrease this readmission rate. More effort needs to be made to ensure equity of access for gallstone patients.     

Curative resection for colorectal cancer in the elderly. Prognostic factors and five-year follow-up

The purpose of this perspective study was to evaluate which prognostic factors predict long-term survival and disease-free survival (DFS) of elderly patients (> or = 65 years) who underwent surgery for colorectal carcinoma. Between January 1992 and December 1998, 196 colorectal cancer patients > or = 65 years (114 M; 82 F; mean age: 75 years; range: 65-92) underwent surgery. One hundred forty-five (74%) of them underwent curative surgery and emergency surgery was more common in patients > or = 75 years of age than among those younger than 75 years (39% vs 23%; p = 0.01). The overall peroperative mortality rate was 3% (n = 6). The median length of hospital stay was 18 days (range: 3-86 days). By univariate analysis, intraoperative bleeding (> or = 500 cc; p = 0.002), length of surgery (> or = 240 min.; p = 0.004), and rectal cancer (p = 0.0001) were associated with complications. By multivariate analysis, only rectal cancer (p = 0.002) was associated with complications. The overall 1, 3-, and 5-year survival rate and DFS rate were 97%, 82%, 74%, and 86%, 64% and 60% respectively. Using multivariate analysis only tumour stage (p < 0.0001) and peroperative blood transfusions (> or = 500 cc; p = 0.006) were associated with outcome. Treatment decisions in elderly patients with colorectal carcinoma should not be influenced by the chronologic age of the patient.     

Steroids to reduce the impact on delirium (STRIDE): a double-blind,randomised, placebo-controlled feasibility trial of pre-operative dexamethasone in people with hip fracture

Neuro-inflammation may be important in the pathogenesis of postoperative delirium following hip fracture surgery. Studies have suggested a potential role for steroids in reducing postoperative delirium; however, the potential efficacy and safety of pre-operative high-dose dexamethasone in this specific population is largely unknown. Conducting such a study could be challenging, considering the multidisciplinary team involvement and the emergency nature of the surgery. The aim of this study was to assess feasibility and effectiveness of dexamethasone given as early as possible following hospital admission for hip fracture, to inform whether a full-scale trial is warranted. This single-centre, randomised, double-blind, placebo-controlled study randomly allocated 79 participants undergoing hip fracture surgery to dexamethasone 20 mg or placebo pre-operatively. Eligibility and recruitment rates, timing of the intervention and adverse events were recorded. Incidence and severity of postoperative delirium were assessed using the 4AT delirium screening tool and the Memorial Delirium Assessment Scale. Postoperative pain, length of stay and mortality were also assessed. The eligibility rate for inclusion was 178/527 (34%), and 57/178 (32%) of eligible patients presented to hospital when no researcher was available (e.g. after-hours, weekends, public holidays). Recruitment was limited mainly by ethical limitations (not including patients with impaired cognition) and lack of weekend staffing. Median (IQR [range]) time from emergency department admission to drug administration was 13.3 (5.9–17.6 [1.8–139.6]) hours. There was a significant difference in delirium severity scores, favouring the dexamethasone group: median (IQR [range]) 5 (3–6 [3–7]) vs. 9 (6–13 [5–14]) in the placebo group, with the probability of superiority effect size being 0.89, p = 0.010. Delirium incidence did not differ between groups: 6/40 (15%) in the dexamethasone group vs. 9/39 (23%) in the placebo group, relative risk (95%CI) 0.65 (0.22–1.65), p = 0.360). A larger randomised controlled trial is feasible and ideally this should include people with existing cognitive impairment, seven days-a-week cover and a multicentre design.     

Recommendations for the nomenclature of cognitive change associated with anaesthesia and surgery—2018

Cognitive change affecting patients after anaesthesia and surgery has been recognised for more than 100 yr. Research into cognitive change after anaesthesia and surgery accelerated in the 1980s when multiple studies utilised detailed neuropsychological testing for assessment of cognitive change after cardiac surgery. This body of work consistently documented decline in cognitive function in elderly patients after anaesthesia and surgery, and cognitive changes have been identified up to 7.5 yr afterwards. Importantly, other studies have identified that the incidence of cognitive change is similar after non-cardiac surgery. Other than the inclusion of non-surgical control groups to calculate postoperative cognitive dysfunction, research into these cognitive changes in the perioperative period has been undertaken in isolation from cognitive studies in the general population. The aim of this work is to develop similar terminology to that used in cognitive classifications of the general population for use in investigations of cognitive changes after anaesthesia and surgery. A multispecialty working group followed a modified Delphi procedure with no prespecified number of rounds comprised of three face-to-face meetings followed by online editing of draft versions.Two major classification guidelines [Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM-5) and National Institute for Aging and the Alzheimer Association (NIA-AA)] are used outside of anaesthesia and surgery, and may be useful for inclusion of biomarkers in research. For clinical purposes, it is recommended to use the DSM-5 nomenclature. The working group recommends that ‘perioperative neurocognitive disorders’ be used as an overarching term for cognitive impairment identified in the preoperative or postoperative period. This includes cognitive decline diagnosed before operation (described as neurocognitive disorder); any form of acute event (postoperative delirium) and cognitive decline diagnosed up to 30 days after the procedure (delayed neurocognitive recovery) and up to 12 months (postoperative neurocognitive disorder).     

Timing of complications following surgery for geriatric hip fractures

IntroductionDespite abundant literature present on complications following hip fracture surgery, few studies have focused on the timing of these complications.Materials and methodsThe 2015–2016 American College of Surgeons – National Surgical Quality Improvement Program database was queried for patients ≥65 years of age undergoing hip fracture surgery, due to trauma, using CPT-Codes for total hip arthroplasty (27130), Hemiarthroplasty (27125) and Open Reduction/Internal Fixation (ORIF) (27236, 27244, 27245). For each complication being studied, the median time to diagnosis was determined along with the interquartile range (IQR). Cox-regression analyses were used to assess complication timings between various surgeries.ResultsA total of 31,738 were included in the final cohort. The median time of occurrence (days) for myocardial infarction was 2 [IQR 1–6], pneumonia 4 [IQR 2–12], stroke/CVA 3 [IQR 1–10], pulmonary embolism 5 [IQR 2–14], urinary tract infection (UTI) 8 [IQR 2–15], deep venous thrombosis (DVT) 9 [IQR 4–17], sepsis 11 [IQR 5–19], death 12 [IQR 6–20], superficial surgical site infection (SSI) 16 [IQR 12–22], deep SSI 23 [IQR 15–24] and organ/space SSI 19 [IQR 15–23]. Undergoing a THA vs. ORIF for hip fracture was associated a relatively early occurrence of pneumonia (day 3 [IQR 1–5.25]; p = 0.029) and urinary tract infection (day 4 [IQR 1–13]; p = 0.035) and a later occurrence of organ/space SSI (day 23.5 [IQR 19.5–26.75]; p = 0.002).ConclusionOrthopaedic trauma surgeons can utilize this data to optimize care strategies during the time-periods of highest risk to prevent complications from occurring early on in the course of post-operative care.     

Predictors of cognitive decline following coronary artery bypass graft surgery

BACKGROUND: A significant number of patients develop cognitive impairment that persists for months following coronary artery bypass grafting (CABG) surgery. Our objectives were to identify patient-related risk factors, processes of care, and the occurrence of any perioperative complications associated with cognitive decline. METHODS: Nine hundred thirty-nine patients enrolled in the Processes, Structures, and Outcomes of Care in Cardiac Surgery study undergoing CABG-only surgery at 14 Veterans Administration medical centers between 1992 and 1996 completed a short battery of cognitive tests at baseline and 6-months post-CABG. The composite cognitive score was based on the sum of errors for each individual item in the battery. Multiple linear regression analyses were used to identify independent predictors of the 6-month composite cognitive score. RESULTS: In multivariable analyses, patient characteristics associated with cognitive decline included cerebrovascular disease (p = 0.009), peripheral vascular disease (p = 0.007), history of chronic disabling neurologic illness (p = 0.016), and living alone (p = 0.049), while the number of years of education (p = 0.001) was inversely related to cognitive decline. After adjustment for baseline patient risk factors, the presence of any postoperative complication(s) (p = 0.001) was also associated with cognitive decline while cardiopulmonary bypass time (p = 0.008) was inversely related to cognitive decline. CONCLUSIONS: Patients with noncoronary manifestations of atherosclerosis, chronic disabling neurologic illness, or limited social support are at risk for cognitive decline after CABG surgery. In contrast, more years of education were associated with less cognitive decline. Preoperative assessment of risk factors identified in this study may be useful when counseling patients about the risk for cognitive decline following CABG surgery.     

A randomised clinical trial comparing the flexible fibrescope and the Pentax Airway Scope (AWS)® for awake oral tracheal intubation

We compared awake fibreoptic intubation with awake intubation using the Pentax Airway Scope^® in 40 adult patients. Sedation was achieved using a target‐controlled remifentanil infusion of 1–5 ng.ml^?1 and midazolam. The airway was anaesthetised with lidocaine spray and gargle. The total procedure time – a composite of sedation time, topical anaesthesia time and intubation time – was recorded. The operator's impression of the ease of the procedure and the patients' reported comfort were recorded on a 0–100 mm visual analogue scale. The median (IQR [range]) for total procedure time was 900 (739–1059 [616–1215]) s with the fibrescope and 651 (601–720 [498–900]) s with the Pentax Airway Scope (p = 0.0001). The median (IQR [range]) intubation time was 420 (283–480 [120–608]) s with the fibrescope and 183 (144–220 [107–420]) s with the Pentax Airway Scope (p = 0.0002). The median (IQR [range]) visual analogue scores for the operator's ease of intubation for the fibrescope and Pentax Airway Scope were 83.6 (72.0–98.0 [49.0–100.0]) and 86.8 (84.0–91.0 [61.0–100.0]), respectively (p = 0.3507). The median (IQR [range]) visual analogue score for patient comfort was 85.5 (81.0–97.0 [69.0–100.0]) and 79.4 (74.0–85.0 [59.0–100.0]) for the fibrescope and Pentax Airway Scope, respectively (p = 0.06). Total procedure time was significantly shorter with the Pentax Airway Scope compared with the fibrescope, with no difference in procedure difficulty or patient discomfort.     

Physical Fitness Measures as Potential Markers of Low Cognitive Function in Japanese Community-Dwelling Older Adults without Apparent Cognitive Problems

Detecting signs of cognitive impairment as early as possible is one of the most urgent challenges in preventive care of dementia. It has still been unclear whether physical fitness measures can serve as markers of low cognitive function, a sign of cognitive impairment, in older people free from dementia. The aim of the present study was to examine an association between each of five physical fitness measures and global cognition in Japanese community-dwelling older adults without apparent cognitive problems. The baseline research of the Sasaguri Genkimon Study was conducted from May to August 2011 in Sasaguri town, Fukuoka, Japan. Of the 2,629 baseline subjects who were aged 65 years or older and not certified as individuals requiring nursing care by the town, 1,552 participants without apparent cognitive problems (Mini-Mental State Examination score ≥24) were involved in the present study (59.0% of the baseline subjects, median age: 72 years, men: 40.1%). Global cognitive function was measured by the Japanese version of the Montreal Cognitive Assessment. Handgrip strength, leg strength, sit-to-stand rate, gait speed, and one-leg stand time were examined as physical fitness measures. In multiple linear regression analyses, each of the five physical fitness measures was positively associated with the Montreal Cognitive Assessment score after adjusting for age and sex (p < 0.001). These associations were preserved after additional adjustment for years of formal education, body mass index, and other confounding factors (p < 0.001). The present study first demonstrated the associations between multiple aspects of physical fitness and global cognitive function in Japanese community-dwelling older people without apparent cognitive problems. These results suggest that each of the physical fitness measures has a potential as a single marker of low cognitive function in older populations free from dementia and thereby can be useful in community-based preventive care of dementia.

Key points

• There is a great need for identifying lifestyle-related markers which help detect subtle cognitive impairment in the preclinical or earlier phase of dementia.
• In the present study, each of the five physical fitness measures employed was linearly and positively associated with the Montreal Cognitive Assessment score in the present older adults without apparent cognitive problems, after adjusting for age, sex, education, body mass index, and other confounding factors.
• The results suggest the potential of each physical fitness measure as a single lifestyle-related marker of low cognitive function in the population, which can be useful in community-based preventive care of dementia.

Key words: Cognitive screening, community-based study, cross-sectional study, mild cognitive impairment, physical function, primary prevention     

The influence of anesthetic techniques on postoperative cognitive function in elderly patients undergoing hip fracture surgery: General vs spinal anesthesia

BackgroundHip fracture is common and morbid in elderly patients. Postoperative cognitive dysfunction (POCD) is also very common in these subjects undergoing surgery with an incidence which exceeds 40% in some reports. To date, the evidence is ambiguous as to whether anesthetic technique may affect the patients’ outcome as far as postoperative cognitive function is concerned.ObjectiveThe aim of this study was to compare the effect of general and subarachnoid (spinal) anesthesia on the development of POCD up to 30 days after surgery in elderly patients undergoing hip fracture surgery.Methods Subjects over 65 years with hip fracture undergoing surgery were recruited for this study. They were enrolled and randomized to receive either general anesthesia (GA group) or subarachnoid (spinal) anesthesia (S group). Cognitive function was assessed using a battery of neuropsychological tests undertaken preoperatively and at 30 days postoperatively. The incidence of delirium was examined during the same period and their functional status, in terms of activities of daily living was also recorded.ResultsA total of seventy patients, 33 men and 37 females, mean age of 76 years were analyzed. Thirty-three patients received general anesthesia (GA group) and 37 subarachnoid (spinal) anesthesia (S group). The two groups of patients were similar with respect to baseline characteristics, comorbidities and perioperative data. The results of neuropsychological testing showed that there were no significant differences between the groups in eight out of ten neurocognitive tests at baseline and 30 days after surgery. There was a statistically significant decline of the Instrumental Activities of Daily Living Scale score in S group compared with group GA on the 30th postoperative day (p = 0.043). A significant decline was also present in Color-Word Task test in S group compared with group GA at baseline (p = 0.014) and 30 days postoperatively (p = 0.003). Postoperative delirium was present in four patients (12%) for the GA group, and in 10 patients (27%) for the group receiving subarachnoid anesthesia.ConclusionWe concluded that the choice of anesthesia modality does not appear to influence the emergence of postoperative cognitive dysfunction in elderly patients undergoing hip fracture surgery.     

Surgical treatment of advanced colorectal cancer in the elderly

The aim of the study was to compare the short and long-term outcomes of older and younger colorectal cancer patients with advanced disease resected with a curative intent. Six hundred and ninety-two patients were analysed. Four hundred and seventy-nine patients were younger than 70 years (Group 1), and 213 were 70 years of age or above (Group 2). The overall perioperative mortality rate in the younger group was 0.8% (n = 7), as against 1.4% (n = 3) in the elderly group (p = NS). The morbidity rates were 35% and 42%, respectively (p = NS). At univariate analysis, the elderly patients had a worse overall survival compared to the younger group, when only patients undergoing postoperative chemo-radiotherapy were considered (54% vs 67% overall survival at 5 years; p = 0.03). Using logistic regression analysis, tumour stage (p < 0.0001) and radicality of surgery (p < 0.0001) correlated significantly with overall survival rates in the elderly. Colorectal surgery for malignancy can be performed safely in the elderly with acceptable morbidity and mortality rates and long-term survival.     

Intelligence quotient scores at the age of 6 years in children anaesthetised before the age of 5 years

We analysed the association of independent variables with non‐verbal cognition at 6 years in children with complete data (3441 from a cohort of 9901), of whom 415 were anaesthetised before the age of 5 years. Using multivariable regression, cognition was reduced by a mean (95% CI) score for children: anaesthetised before the age of 5 years, 2.1 (0.7–3.5), p = 0.004; born prematurely, 9.8 (4.1–15.4), p = 0.001; whose mothers smoked while pregnant, 2.3 (0.8–3.8), p = 0.004; whose mothers had lower IQ scores, 0.3 (0.2–0.3) for each unit reduction in maternal IQ, p < 0.0001. The association of child IQ with exposure to anaesthetic drugs was sensitive to missing data.     

Choice reaction time in patients with post-operative cognitive dysfunction

Background: Post‐operative cognitive dysfunction (POCD) is detected by administration of a neuropsychological test battery. Reaction time testing is at present not included as a standard test. Choice reaction time (CRT) data from the first International Study of Post‐operative Cognitive Dysfunction study were collected, but the association between POCD and reaction time has not been presented before. We hypothesized that CRT could be used as a screening tool for POCD. Methods: Patients aged 60 years or older scheduled for major surgery with general anaesthesia were recruited from 13 centres in nine countries. CRT was measured 52 times using the four boxes test. Patients performed the test before surgery (n=1083), at 1 week (n=926) and at 3 months (n=852) post‐operatively. CRT for the individual patient was determined as the median time of correct responses. The usefulness of the CRT as a screening tool for POCD was determined by the receiver–operator characteristic (ROC) curve. Results: Patients with POCD 1 week after surgery had a significantly longer reaction time compared with patients without POCD: 857 (221) vs. 762 (201) ms, respectively (P<0.0001). Also at 3 months, patients with POCD had a significantly longer CRT. ROC curves revealed that a reaction time of 813 ms was the most appropriate cut‐off at 1 week and 762 ms at 3 months but the positive predictive value for POCD was low: 34.4% and 14.7%, respectively. Conclusions: Post‐operative cognitive dysfunction is associated with impaired performance in the CRT test but the test is a poor predictor of POCD.     

Femoral impaction bone allografting with an Exeter cemented collarless, polished, tapered stem in revision hip replacement: a mean follow-up of 10.5 years

Femoral impaction bone allografting has been developed as a means of restoring bone stock in revision total hip replacement. We report the results of 75 consecutive patients (75 hips) with a mean age of 68 years (35 to 87) who underwent impaction grafting using the Exeter collarless, polished, tapered femoral stem between 1992 and 1998. The mean follow-up period was 10.5 years (6.3 to 14.1). The median pre-operative bone defect score was 3 (interquartile range (IQR) 2 to 3) using the Endo-Klinik classification. The median subsidence at one year post-operatively was 2 mm (IQR 1 to 3). At the final review the median Harris hip score was 80.6 (IQR 67.6 to 88.9) and the median subsidence 2 mm (IQR 1 to 4). Incorporation of the allograft into trabecular bone and secondary remodelling were noted radiologically at the final follow-up in 87% (393 of 452 zones) and 40% (181 of 452 zones), respectively. Subsidence of the Exeter stem correlated with the pre-operative Endo-Klinik bone loss score (p = 0.037). The degree of subsidence at one year had a strong association with long-term subsidence (p < 0.001). There was a significant correlation between previous revision surgery and a poor Harris Hip score (p = 0.028), and those who had undergone previous revision surgery for infection had a higher risk of complications (p = 0.048). Survivorship at 10.5 years with any further femoral operation as the end-point was 92% (95% confidence interval 82 to 97).