Geriatric Surgery Produces a Hypoactive Molecular Phenotype in the Monocyte Immune Gene Transcriptome.

Surgery is a major challenge for the immune system, but little is known about the immune response of geriatric patients to surgery. We therefore investigated the impact of surgery on the molecular signature of circulating CD14+ monocytes, cells implicated in clinical recovery from surgery, in older patients. We enrolled older patients having elective joint replacement (N = 19) or spine (N = 16) surgery and investigated pre- to postoperative expression changes in 784 immune-related genes in monocytes. Joint replacement altered the expression of 489 genes (adjusted p < 0.05), of which 38 had a |logFC| > 1. Spine surgery changed the expression of 209 genes (adjusted p < 0.05), of which 27 had a |logFC| > 1. In both, the majority of genes with a |logFC| > 1 change were downregulated. In the combined group (N = 35), 471 transcripts were differentially expressed (adjusted p < 0.05) after surgery; 29 had a |logFC| > 1 and 72% of these were downregulated. Notably, 21 transcripts were common across procedures. Thus, elective surgery in older patients produces myriad changes in the immune gene transcriptome of monocytes, with many suggesting development of an immunocompromised/hypoactive phenotype. Because monocytes are strongly implicated in the quality of surgical recovery, this signature provides insight into the cellular and molecular mechanisms of the immune response to surgery and warrants further study as a potential biomarker for predicting poor outcomes in older surgical patients.

Brief Preoperative Screening for Frailty and Cognitive Impairment Predicts Delirium after Spine Surgery.

BACKGROUND: Frailty and cognitive impairment are associated with postoperative delirium, but are rarely assessed preoperatively. The study was designed to test the hypothesis that preoperative screening for frailty or cognitive impairment identifies patients at risk for postoperative delirium (primary outcome). METHODS: In this prospective cohort study, the authors administered frailty and cognitive screening instruments to 229 patients greater than or equal to 70 yr old presenting for elective spine surgery. Screening for frailty (five-item FRAIL scale [measuring fatigue, resistance, ambulation, illness, and weight loss]) and cognition (Mini-Cog, Animal Verbal Fluency) were performed at the time of the preoperative evaluation. Demographic data, perioperative variables, and postoperative outcomes were gathered. Delirium was the primary outcome detected by either the Confusion Assessment Method, assessed daily from postoperative day 1 to 3 or until discharge, if patient was discharged sooner, or comprehensive chart review. Secondary outcomes were all other-cause complications, discharge not to home, and hospital length of stay. RESULTS: The cohort was 75 [73 to 79 yr] years of age, 124 of 219 (57%) were male. Many scored positive for prefrailty (117 of 218; 54%), frailty (53 of 218; 24%), and cognitive impairment (50 to 82 of 219; 23 to 37%). Fifty-five patients (25%) developed delirium postoperatively. On multivariable analysis, frailty (scores 3 to 5 [odds ratio, 6.6; 95% CI, 1.96 to 21.9; P = 0.002]) versus robust (score 0) on the FRAIL scale, lower animal fluency scores (odds ratio, 1.08; 95% CI, 1.01 to 1.51; P = 0.036) for each point decrease in the number of animals named, and more invasive surgical procedures (odds ratio, 2.69; 95% CI, 1.31 to 5.50; P = 0.007) versus less invasive procedures were associated with postoperative delirium. CONCLUSIONS: Screening for frailty and cognitive impairment preoperatively using the FRAIL scale and the Animal Verbal Fluency test in older elective spine surgery patients identifies those at high risk for the development of postoperative delirium.

Retrospective Analysis of Perioperative Variables Associated With Postoperative Delirium and Other Adverse Outcomes in Older Patients After Spine Surgery.

BACKGROUND: The aim of this retrospective study was to identify perioperative variables predictive of the development of delirium in older surgical patients after spine surgery. MATERIALS AND METHODS: We collected preoperative, intraoperative, and postoperative data on patients 65 years of age and above having spine surgery between July 1, 2015 and March 15, 2017. The primary outcome was the development of postoperative delirium. Data were analyzed using univariate and multivariable analysis. RESULTS: Among the 716 patients included in this study 127 (18%) developed postoperative delirium. On multivariable analysis, independent predictors of postoperative delirium included older age (odds ratio [OR]=1.04; 95% confidence interval [CI], 1.00-1.09; P=0.048), American Society of Anesthesiologists physical status >2 (OR=1.89 [95% CI, 1.04-3.59]; P=0.042), metabolic equivalents of task <4 (OR=1.84 [95% CI, 1.10-3.07]; P=0.019), depression (OR=2.01 [95% CI, 1.21-3.32]; P=0.006), nonelective surgery (OR=4.81 [95% CI, 1.75-12.79]; P=0.002), invasive surgical procedures (OR=1.97 [95% CI, 1.10-3.69]; P=0.028) and higher mean pain scores on postoperative day 1 (OR=1.28 [95% CI, 1.11-1.48]; P<0.001). CONCLUSIONS: Postoperative delirium is a common complication in older patients after spine surgery, and there are several perioperative risk factors associated with its development.

Patient and Provider Perspectives on a Mind-Body Program for Grieving Older Adults.

BACKGROUND: Spousal bereavement in older age is a major stressor associated with an increase in both mental and physical problems. The Stress Management and Resiliency Training: Relaxation Response Resiliency Program (SMART-3RP) is an 8-week multimodal mind-body program that targets stress and has been found efficacious in decreasing the mental and physical manifestations of stress in varied populations. This qualitative study sought to investigate the relevance, credibility, and feasibility of the SMART-3RP in the community. METHODS: Focus groups were conducted among both older widowed adults and providers who support them in the community (eg, chaplains, hospice bereavement coordinators). Transcripts were coded independently by coders trained in qualitative research. Codebooks were created based on both general themes and detailed subthemes present in the transcripts. RESULTS: Findings from 4 focus groups revealed a general convergence between the needs of recently widowed older adults reported by widow(er)s and community providers alike and needs identified in the literature. Several components of the SMART-3RP target many of these needs (eg, social support, stress awareness, coping skills), making both community providers and widow(er)s report that the SMART-3RP is logical (89%) and would be helpful (100%) and successful in reducing symptoms (78%). Additionally, all widow(er)s reported a willingness to participate (100%). Feedback from the focus groups was used to adapt the SMART-3RP to improve its relevance to grief-related stress. CONCLUSIONS: Our findings suggest that the SMART-3RP may be helpful in decreasing somatic and psychological distress in older adults who have lost a spouse.