Concepts for exercise therapy in prehabilitation for elderly people with frailty or pre-frailty prior to elective surgery. A scoping review.

BACKGROUND: Frailty is a state of reduced functional capacities in older people that can be reversed through multimodal therapy concepts. The effect of preoperative prehabilitation on frailty has been examined, but the heterogeneity of exercise regimens has prevented conclusive evidence. This scoping review analyses prehabilitation interventions, particularly exercise methods, published in trials for prefrail and frail elderly patients. METHOD: We identified studies evaluating prehabilitation for frail elderly using the framework of Arksey and O'Malley. Five scientific databases were searched until March 2022. Articles were screened by two independent reviewers. Data extraction included, but was not limited to, study design, intervention protocol of the prehabilitation including exercise therapy and additional interventions, and safety of the reported exercise concepts. RESULTS: Nineteen studies were included, offering an insight into the utilized prehabilitation concepts for exercise. All study interventions were based around exercise programs, potentially with complementary interventions. Twelve studies based their exercise programs on a combination of endurance and strength training. Breathing exercises were prescribed in five studies, flexibility routines in five, and one study included balance training. Further interventions included nutritional counselling/supplementation in nine studies, smoking/alcohol cessation in five, in addition to two physiological and three medical/pharmaceutical interventions. DISCUSSION: Prehabilitation for the frail elderly is safe and feasible. The general concept of prehabiliation for frail patients is promising. An exercise program should focus on improving the patient's endurance and strength, considering the positive effects that can be provided by breathing exercises and other additional interventions, such as nutritional support or lifestyle counselling.

Corrigendum: The functional trajectory in frail compared with non-frail critically ill patients during the hospital stay.

[This corrects the article DOI: 10.3389/fmed.2021.748812.].

Quality contract 'prevention of postoperative delirium in the care of elderly patients' study protocol: a non-randomised, pre-post, monocentric, prospective trial.

INTRODUCTION: Postoperative delirium (POD) is seen in approximately 15% of elderly patients and is related to poorer outcomes. In 2017, the Federal Joint Committee (Gemeinsamer Bundesausschuss) introduced a 'quality contract' (QC) as a new instrument to improve healthcare in Germany. One of the four areas for improvement of in-patient care is the 'Prevention of POD in the care of elderly patients' (QC-POD), as a means to reduce the risk of developing POD and its complications.The Institute for Quality Assurance and Transparency in Health Care identified gaps in the in-patient care of elderly patients related to the prevention, screening and treatment of POD, as required by consensus-based and evidence-based delirium guidelines. This paper introduces the QC-POD protocol, which aims to implement these guidelines into the clinical routine. There is an urgent need for well-structured, standardised and interdisciplinary pathways that enable the reliable screening and treatment of POD. Along with effective preventive measures, these concepts have a considerable potential to improve the care of elderly patients. METHODS AND ANALYSIS: The QC-POD study is a non-randomised, pre-post, monocentric, prospective trial with an interventional concept following a baseline control period. The QC-POD trial was initiated on 1 April 2020 between Charité-Universitätsmedizin Berlin and the German health insurance company BARMER and will end on 30 June 2023. INCLUSION CRITERIA: patients 70 years of age or older that are scheduled for a surgical procedure requiring anaesthesia and insurance with the QC partner (BARMER). Exclusion criteria included patients with a language barrier, moribund patients and those unwilling or unable to provide informed consent. The QC-POD protocol provides perioperative intervention at least two times per day, with delirium screening and non-pharmacological preventive measures. ETHICS AND DISSEMINATION: This protocol was approved by the ethics committee of the Charité-Universitätsmedizin, Berlin, Germany (EA1/054/20). The results will be published in a peer-reviewed scientific journal and presented at national and international conferences. TRIAL REGISTRATION NUMBER: NCT04355195.

The association of chronic pain and postoperative delirium: a prospective observational cohort study.

BACKGROUND: Postoperative delirium (POD) is an acute and common complication after surgery that can increase morbidity and mortality. Few previous studies with inconsistent findings have examined the association of preoperative pain and POD. Our purpose is to investigate the association of preoperative chronic pain and POD. METHODS: This prospective observational cohort study included 200 patients ≥ 18 years scheduled for elective surgery under general anaesthesia in a tertiary care hospital. POD was defined as meeting diagnostic criteria during the study visits (according to delirium screening tests and the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), or by diagnosis of the responsible physicians. Chronic pain was defined as pain lasting six months or longer. Features of chronic pain were assessed with the German Pain Questionnaire, including the Depression Anxiety and Stress Scale-21 (DASS-21). Associations with POD were assessed using logistic regression analysis adjusting for confounding factors. RESULTS: Thirty-nine (22%) out of 176 patients developed POD. Chronic pain was not associated with POD after adjustment for ASA physical status, duration of anesthesia and DASS-21 Anxiety score (Odds ratio [OR], 95%-Confidence Interval [CI], 2.216 [0.968;5.070], P=0.060). A subgroup analysis of chronic pain patients revealed that current pain intensity was higher in patients with POD. CONCLUSIONS: Preoperative chronic pain was no independent predictor for POD. Current pain intensity was higher in chronic pain patients with POD. This indicates that certain features of pain might be influential. Further research is needed to examine different forms of preoperative pain and their possible influence on POD.

[Frailty Diagnosis in Different Settings]. / Frailty-Diagnostik in verschiedenen AINS-Settings.

Frailty Syndrome has been recognized in several settings as a major predictor of negative outcomes. A frailty diagnosis can have important consequences for clinical decision-making and provides the opportunity to implement preventive strategies. Despite its importance, a gold standard for the diagnosis of frailty is still lacking. There are distinct frailty models and a large number of assessments are available, and they vary greatly in terms of time, training, and equipment necessary, but also on their relevance to specific outcomes. Diagnostic tools must be based on the resources available and on their relevance for the particular setting. The current review offers insights on current models and the most successful diagnostic instruments used in the anesthesia, intensive care, emergency, and palliative settings.

Frailty als Herausforderung im klinischen Alltag.

In order to prevent short-term complication, patients with frailty syndrome require special attention and care in the perioperative context. The implementation of a frailty screening and if possible, an advanced geriatric assessment in the clinical routine should take into account the clinical setting, the patient population as well as time and human resources. Individual treatment pathways must allow for a multidisciplinary exchange and a multimodal approach when dealing with these challenging patients. Key aspects of such pathways include physiotherapeutic interventions, nutritional counselling, adequate pain medication, delirium prevention, patient blood management and extended perioperative monitoring. An interdisciplinary shared decision-making process together with patients can help develop realistic and individual treatment concepts to improve safety and outcome of frail patients.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial.

BACKGROUND: Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery. METHODS: Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention. DISCUSSION: Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.

A comparison of first-attempt cannulation success of peripheral venous catheter systems with and without wings and injection ports in surgical patients-a randomized trial.

BACKGROUND: A peripheral venous catheter (PVC) is the most widely used device for obtaining vascular access, allowing the administration of fluids and medication. Up to 25% of adult patients, and 50% of pediatric patients experience a first-attempt cannulation failure. In addition to patient and clinician characteristics, device features might affect the handling and success rates. The objective of the study was to compare the first-attempt cannulation success rate between PVCs with wings and a port access (Vasofix® Safety, B. Braun, abbreviated hereon in as VS) with those without (Introcan® Safety, B. Braun, abbreviated hereon in as IS) in an anesthesiological cohort. METHODS: An open label, multi-center, randomized trial was performed. First-attempt cannulation success rates were examined, along with relevant patient, clinician, and device characteristics with univariate and multivariate analyses. Information on handling and adherence to use instructions was gathered, and available catheters were assessed for damage. RESULTS: Two thousand three hundred four patients were included in the intention to treat analysis. First-attempt success rate was significantly higher with winged and ported catheters (VS) than with the non-winged, non-ported design (IS) (87.5% with VS vs. 78.2% with IS; PChi < .001). Operators rated the handling of VS as superior (rating of "good" or "very good: 86.1% VS vs. 20.8% IS, PChi < .001). Reinsertion of the needle into the catheter after partial withdrawal-prior or during the catheterization attempt-was associated with an increased risk of cannulation failure (7.909, CI 5.989-10.443, P < .001 and 23.023, CI 10.372-51.105, P < .001, respectively) and a twofold risk of catheter damage (OR 1.999, CI 1.347-2.967, P = .001). CONCLUSIONS: First-attempt cannulation success of peripheral, ported, winged catheters was higher compared to non-ported, non-winged devices. The handling of the winged and ported design was better rated by the clinicians. Needle reinsertions are related to an increase in rates of catheter damage and cannulation failure. TRIAL REGISTRATION: ClinicalTrials.gov, Identifier: NCT02213965 , Date: 12/08/2014.

Functional Connectivity of the Supplementary and Presupplementary Motor Areas in Postoperative Transition Between Stages of Frailty.

BACKGROUND: Frailty is a multietiological geriatric syndrome of run-down physical reserves with high vulnerability to stressors. Transitions between physical robustness and frailty often occur in the context of medical interventions. Studies suggest that neurological disorders contribute to faster progression of frailty. In a previous cross-sectional study we found altered functional connectivity of supplementary motor area (SMA) in (pre)frail compared to robust patients. We analyzed functional connectivity of the SMA and presupplementary motor area (pre-SMA) in patients with postoperative transitions between physical robustness and stages of frailty. METHODS: We investigated 120 cognitively healthy patients (49.2% robust, 47.5% prefrail, 3.3% frail, 37.5% female, median age 71 [65-87] years) undergoing elective surgery from the BioCog project, a multicentric prospective cohort study on postoperative delirium and cognitive dysfunction. Assessments took place 14 days before and 3 months after surgery, comprising assessments of a modified frailty phenotype according to Fried and resting-state functional magnetic resonance imaging at 3 T. The associations between functional connectivity of the SMA and pre-SMA networks, preoperative frailty stages, and postoperative transitions were examined using mixed linear effects models. RESULTS: Nineteen patients showed physical improvement after surgery, 24 patients progressed to (pre)frailty and in 77 patients no transition was observed. At follow-up, 57 (47.5%) patients were robust, 52 (43.3%) prefrail, and 11 (9.2%) frail. Lower functional connectivity in the pre-SMA network was associated with more unfavorable postoperative transition types. An exploratory analysis suggested that the association was restricted to patients who were prefrail at baseline. There was no association of transition type with SMA functional connectivity in the primary analysis. In an exploratory analysis, transition from prefrailty to robustness was associated with higher functional connectivity and progression in robust patients was associated with higher SMA network segregation. CONCLUSIONS: Our findings implicate that dysfunctions of cortical networks involved in higher cognitive control of motion are associated with postoperative transitions between frailty stages. The pre-SMA may be a target for neurofeedback or brain stimulation in approaches to prevent frailty. Clinical Trials Registration Number: NCT02265263.

The Functional Trajectory in Frail Compared With Non-frail Critically Ill Patients During the Hospital Stay.

Background: Long-term outcome is determined not only by the acute critical illness but increasingly by the reduced functional reserve of pre-existing frailty. The patients with frailty currently account for one-third of the critically ill, resulting in higher mortality. There is evidence of how frailty affects the intrahospital functional trajectory of critically ill patients since prehospital status is often missing. Methods: In this prospective single-center cohort study at two interdisciplinary intensive care units (ICUs) at a university hospital in Germany, the frailty was assessed using the Clinical Frailty Scale (CFS) in the adult patients with critical illness with an ICU stay >24 h. The functional status was assessed using the sum of the subdomains "Mobility" and "Transfer" of the Barthel Index (MTB) at three time points (pre-hospital, ICU discharge, and hospital discharge). Results: We included 1,172 patients with a median age of 75 years, of which 290 patients (25%) were frail. In a propensity score-matched cohort, the probability of MTB deterioration till hospital discharge did not differ in the patients with frailty (odds ratio (OR) 1.3 [95% CI 0.8-1.9], p = 0.301), confirmed in several sensitivity analyses in all the patients and survivors only. Conclusion: The patients with frailty have a reduced functional status. Their intrahospital functional trajectory, however, was not worse than those in non-frail patients, suggesting a rehabilitation potential of function in critically ill patients with frailty.

Telemedicine in Intensive Care Units: Scoping Review.

BACKGROUND: The role of telemedicine in intensive care has been increasing steadily. Tele-intensive care unit (ICU) interventions are varied and can be used in different levels of treatment, often with direct implications for the intensive care processes. Although a substantial body of primary and secondary literature has been published on the topic, there is a need for broadening the understanding of the organizational factors influencing the effectiveness of telemedical interventions in the ICU. OBJECTIVE: This scoping review aims to provide a map of existing evidence on tele-ICU interventions, focusing on the analysis of the implementation context and identifying areas for further technological research. METHODS: A research protocol outlining the method has been published in JMIR Research Protocols. This review follows the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A core research team was assembled to provide feedback and discuss findings. RESULTS: A total of 3019 results were retrieved. After screening, 25 studies were included in the final analysis. We were able to characterize the context of tele-ICU studies and identify three use cases for tele-ICU interventions. The first use case is extending coverage, which describes interventions aimed at extending the availability of intensive care capabilities. The second use case is improving compliance, which includes interventions targeted at improving patient safety, intensive care best practices, and quality of care. The third use case, facilitating transfer, describes telemedicine interventions targeted toward the management of patient transfers to or from the ICU. CONCLUSIONS: The benefits of tele-ICU interventions have been well documented for centralized systems aimed at extending critical care capabilities in a community setting and improving care compliance in tertiary hospitals. No strong evidence has been found on the reduction of patient transfers following tele-ICU intervention. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/19695.

Comparison of volume-controlled, pressure-controlled, and chest compression-induced ventilation during cardiopulmonary resuscitation with an automated mechanical chest compression device: A randomized clinical pilot study.

AIM OF THE STUDY: Automated mechanical chest compression devices (AMCCDs) can help performing high-quality cardiopulmonary resuscitation (CPR). Guidelines for CPR are lacking information about the optimal ventilation mode during CPR using AMCCDs. Aim of this pilot study was to compare three common ventilation modes during CPR using AMCCD. METHODS: In this randomized controlled trial, we included patients with an out-of-hospital cardiac arrest arriving at the resuscitation room receiving chest compressions via AMCCD with an expected continuation of at least 15 min. Patients were randomly assigned to three groups: biphasic positive airway pressure with assisted spontaneous ventilation (BIPAP) with assisted spontaneous breathing, continuous positive airway pressure (CPAP) and volume-controlled ventilation (VCV). Outcomes were tidal volume, respiratory minute volume, and end-tidal CO2 during the study period. Groups were compared using generalized linear models. Data is given as median and interquartile ranges. RESULTS: Of 53 screened patients, 30 were randomized. The tidal volume was significantly (p < 0.05) lower in patients of the CPAP group (68 [64-83] ml) compared with those of the BIPAP (349 [137-500] ml), while the respiratory minute volume differed between the CPAP group (6.2 [5.3-8.1] l/min) and both the BIPAP (7.1 [6.7-10.2] l/min) and VCV group (7.2 [3.7-8.4] l/min). CONCLUSIONS: All ventilation modes achieved an adequate respiratory minute volume during CPR with an AMCCD. However, BIPAP seems to be superior due to the higher tidal volume. Therefore, we recommend starting mechanical ventilation when using AMCCD with BIPAP ventilation to avoid risks related to dead space ventilation.

Preoperative medication use and development of postoperative delirium and cognitive dysfunction.

Postoperative delirium (POD) and postoperative (neuro-)cognitive disorder (POCD) are frequent and serious complications after operations. We aim to investigate the association between pre-operative polypharmacy and potentially inappropriate medications and the development of POD/POCD in elderly patients. This investigation is part of the European BioCog project (www.biocog.eu), a prospective multicenter observational study with elderly surgical patients. Patients with a Mini-Mental State Examination score less than or equal to 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method (for the intensive care unit [ICU]), and a patient chart review. POCD was assessed 3 months after surgery with a neuropsychological test battery. Pre-operative long-term medication was evaluated in terms of polypharmacy (≥5 agents) and potentially inappropriate medication (defined by the PRISCUS and European list of potentially inappropriate medications [EU(7)-PIM] lists), and associations with POD and POCD were analyzed using logistic regression analysis. Eight hundred thirty-seven participants were included for analysis of POD and 562 participants for POCD. Of these, 165 patients (19.7%) fulfilled the criteria of POD and 60 (10.7%) for POCD. After adjusting for confounders, pre-operative polypharmacy and intake of potentially inappropriate medications could not be shown to be associated with the development of POD nor POCD. We found no associations between pre-operative polypharmacy and potentially inappropriate medications and development of POD and POCD. Future studies should focus on the evaluation of drug interactions to determine whether patients benefit from a pre-operative adjustment.

Correction: Benchmarking Triage Capability of Symptom Checkers Against That of Medical Laypersons: Survey Study.

[This corrects the article DOI: 10.2196/24475.].

Benchmarking Triage Capability of Symptom Checkers Against That of Medical Laypersons: Survey Study.

BACKGROUND: Symptom checkers (SCs) are tools developed to provide clinical decision support to laypersons. Apart from suggesting probable diagnoses, they commonly advise when users should seek care (triage advice). SCs have become increasingly popular despite prior studies rating their performance as mediocre. To date, it is unclear whether SCs can triage better than those who might choose to use them. OBJECTIVE: This study aims to compare triage accuracy between SCs and their potential users (ie, laypersons). METHODS: On Amazon Mechanical Turk, we recruited 91 adults from the United States who had no professional medical background. In a web-based survey, the participants evaluated 45 fictitious clinical case vignettes. Data for 15 SCs that had processed the same vignettes were obtained from a previous study. As main outcome measures, we assessed the accuracy of the triage assessments made by participants and SCs for each of the three triage levels (ie, emergency care, nonemergency care, self-care) and overall, the proportion of participants outperforming each SC in terms of accuracy, and the risk aversion of participants and SCs by comparing the proportion of cases that were overtriaged. RESULTS: The mean overall triage accuracy was similar for participants (60.9%, SD 6.8%; 95% CI 59.5%-62.3%) and SCs (58%, SD 12.8%). Most participants outperformed all but 5 SCs. On average, SCs more reliably detected emergencies (80.6%, SD 17.9%) than laypersons did (67.5%, SD 16.4%; 95% CI 64.1%-70.8%). Although both SCs and participants struggled with cases requiring self-care (the least urgent triage category), SCs more often wrongly classified these cases as emergencies (43/174, 24.7%) compared with laypersons (56/1365, 4.10%). CONCLUSIONS: Most SCs had no greater triage capability than an average layperson, although the triage accuracy of the five best SCs was superior to the accuracy of most participants. SCs might improve early detection of emergencies but might also needlessly increase resource utilization in health care. Laypersons sometimes require support in deciding when to rely on self-care but it is in that very situation where SCs perform the worst. Further research is needed to determine how to best combine the strengths of humans and SCs.

Preoperative Comparison of Three Anticholinergic Drug Scales in Older Adult Patients and Development of Postoperative Delirium: A Prospective Observational Study.

BACKGROUND: Postoperative delirium (POD) is a frequent and serious complication after surgery. Evidence of a relationship between anticholinergic medication and the development of delirium is inconclusive, but studies on POD are rare. OBJECTIVES: The objective of this study was to evaluate the anticholinergic load of preoperative medication in older adult patients and its association with the development of POD. METHODS: This investigation was part of the European BioCog project ( http://www.biocog.eu ), a prospective multicenter observational study in older adult surgical patients (ClinicalTrials.gov identifier: NCT02265263, 15 October 2014). Patients with a Mini-Mental State Examination score ≤ 23 points were excluded. POD was assessed up to 7 days after surgery using the Nursing Delirium Screening Scale, Confusion Assessment Method and a patient chart review. The preoperative anticholinergic load was calculated using the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Cognitive Burden Scale (ACBS), and associations with POD were analyzed using logistic regression analysis adjusting for age, comorbidities, duration of anesthesia and number of drugs used. RESULTS: In total, 837 participants were included for analysis, and 165 patients (19.7%) fulfilled the criteria of POD. After adjusting for confounders, we found no association between preoperative anticholinergic load and the development of POD (ADS [points] odds ratio [OR] 0.928; 95% confidence interval [CI] 0.749-1.150; ARS [points] OR 0.832; 95% CI 0.564-1.227; ACBS [points] OR 1.045; 95% CI 0.842-1.296). CONCLUSION: This study found no association between the anticholinergic load of drugs used preoperatively and the development of POD in older adult patients without severe preexisting cognitive impairment. Future analyses should examine the influence of intra- and postoperative administration of anticholinergic drugs as well as dosages of and interactions between medications.

Critical illness myopathy precedes hyperglycaemia and high glucose variability.

BACKGROUND: Critical Illness Myopathy (CIM) is a serious ICU complication, and dysglycaemia is widely regarded as a risk factor. Although glucose variability (GV) has been independently linked to ICU mortality, an association with CIM has not been investigated. This study examines the relationship between CIM and GV. METHODS: Retrospective investigation including ICU patients with SOFA ≥8, mechanical ventilation, and CIM diagnostics. Glucose readings were collected every 6 h throughout the first week of treatment, when CIM is thought to develop. GV was measured using standard deviation (SD), coefficient of variability (CV), mean absolute glucose (MAG), mean amplitude of glycaemic excursions (MAGE), and mean of daily difference (MODD). RESULTS: 74 patients were included, and 50 (67.6%) developed CIM. Time on glycaemic target (70-179 mg/dL), caloric and insulin intakes, mean, maximum and minimum blood glucose values were similar for all patients until the 5th day, after which CIM patients exhibited higher mean and maximum glucose levels. Significantly higher GV in CIM patients were observed on day 5 (SD, CV, MAG, MAGE), day 6 (MODD), and day 7 (SD, CV, MAG). CONCLUSIONS: CIM patients developed transient increases in GV and hyperglycaemia only late in the first week, suggesting that myopathy precedes dysglycaemia.

Radiological, Chemical, and Pharmacological Cholinergic System Parameters and Neurocognitive Disorders in Older Presurgical Adults.

BACKGROUND: A pre-existing neurocognitive disorder (NCD) is a relevant factor for the outcome of surgical patients. To improve understanding of these conditions, we investigated the association between parameters of the cholinergic system and NCD. METHOD: This investigation is part of the BioCog project (www.biocog.eu), which is a prospective multicenter observational study including patients aged 65 years and older scheduled for elective surgery. Patients with a Mini-Mental State Examination (MMSE) score ≤23 points were excluded. Neurocognitive disorder was assessed according to the fifth Diagnostic and Statistical Manual of Mental Disorders criteria. The basal forebrain cholinergic system volume (BFCSV) was assessed with magnetic resonance imaging, the peripheral cholinesterase (ChE) activities with point-of-care measurements, and anticholinergic load by analyzing the long-term medication with anticholinergic scales (Anticholinergic Drug Scale [ADS], Anticholinergic Risk Scale [ARS], Anticholinergic Cognitive Burden Scale [ACBS]). The associations of BFCSV, ChE activities, and anticholinergic scales with NCD were studied with logistic regression analysis, adjusting for confounding factors. RESULTS: A total of 797 participants (mean age 72 years, 42% females) were included. One hundred and eleven patients (13.9%) fulfilled criteria for mild NCD and 82 patients (10.3%) for major NCD criteria. We found that AcetylChE activity was associated with major NCD (odds ratio [95% confidence interval]: [U/gHB] 1.061 [1.010, 1.115]), as well as ADS score ([points] 1.353 [1.063, 1.723]) or ARS score, respectively ([points] 1.623 [1.100, 2.397]) with major NCD. However, we found no association between BFCSV or ButyrylChE activity with mild or major NCD. CONCLUSIONS: AcetylChE activity and anticholinergic load were associated with major NCD. Future research should focus on the association of the cholinergic system and the development of postoperative delirium and postoperative NCD.