Influence of mild cognitive impairment on clinical and functional prognosis in older candidates for cardiac surgery.

Introduction: In this study, we analyzed the prognostic impact of mild cognitive impairment (MCI) prior to cardiac surgery on 12-month clinical outcomes in older patients. Method: We performed a longitudinal prospective study of 48 patients undergoing cardiac surgery and 26 neurologically healthy participants aged 65 years or older. All participants underwent a neuropsychological assessment. Functional status, quality of life and frailty were assessed in candidates for surgery. One year after surgery, 24 patients remained in the study. Results: Mild cognitive impairment (MCI) was diagnosed in 35% of the patients at baseline. Postsurgical changes in functionality consisted of a tendency toward impaired basic activities of daily living (BADL) in the MCI group and a statistically significant worsening in instrumental activities of daily living (IADL) in women with MCI. Changes in quality of life consisted of a significant improvement in anxiety-depression in the MCI group and a tendency toward greater pain-discomfort in the non-MCI group. Cognitive status significantly declined only in the non-MCI group. Neither group showed significant changes in frailty. Relative risk analysis showed that patients with a diagnosis of MCI at baseline had a higher risk of cognitive decline at follow-up, while those without a diagnosis of MCI at baseline had a lower risk of impaired IADL. No association was found between MCI and resource use. Preoperative impairment in memory, visuospatial and executive functions was significantly associated with loss of quality of life at follow-up. Impairment of memory and visuospatial function was significantly associated with cognitive decline. Preserved memory was associated with a lower risk of impaired BADL at follow-up. Conclusion: The present study provides clue on the impact of MCI in candidates for cardiac surgery. Preoperative detection of cognitive impairment could be highly valuable to help guide pre- and post-operative management.

Changes in frailty status after cardiac surgery. A prospective cohort study.

BACKGROUND: The concept of frailty has become increasingly familiar in cardiac surgery. Since one of the characteristics of frailty is its reversible nature, efforts are being made to preoperatively decrease the level of frailty. However, the effect that the surgery itself may have in the postoperative frailty status remains still unknown. METHODS: A prospective cohort of 137 patients aged 70 or more undergoing major cardiac surgery were recruited at three hospitals in Spain. Frailty status was assessed preoperatively and six months after surgery using the Fried scale and the Clinical Frailty Scale (CFS). We analyzed the changes in these frailty scores and the transitions between frailty status after surgery. RESULTS: Mean age of participants was 78.3 years. 47.7% were female. Prevalence of frailty was 27.5% with the Fried Scale and 11% with the CFS. Up to 50% of frail patients improved their frailty status after surgery. The distribution of frailty among the study groups at baseline and six months after surgery changed significantly, decreasing the overall burden of frailty after surgery: 27.5% vs 17.4% of frail patients with the Fried Scale and 50.5% vs 29.4% of vulnerable or frail patients with the CFS (p<0.01). CONCLUSIONS: Frailty is a dynamic condition that can be significantly reduced after cardiac surgery, suggesting that cardiac pathology is an important contributor to the preoperative patient's frailty status.

Description of general practitioners' practices when suspecting cognitive impairment. Recourse to care in dementia (Recaredem) study.

OBJECTIVE: General practitioners (GPs) play a major role in the assessment of dementia but it is still unrecognized in primary care and its management is heterogeneous. Our objective is to describe the usual practices, and their determinants, of French GPs in this field. METHODS: GPs' characteristics and practices when facing cognitive decline were collected through a telephone interview and a postal questionnaire. A descriptive analysis of all study variables was conducted. The study of quantitative explanatory variables was done by testing the equality of means and the choice of qualitative variables was based on the chi-square independence test or Fischer test. RESULTS: Hundred two GPs completed the study. GPs were in majority men, working in urban areas. Mean age was 54.4 years old. GPs' feeling of confidence and self-perception of follow-up of national recommendations is linked with their practices. Performing a clinical interview to assess cognitive impairment is linked with good communication skills. GPs feel less confident to give information about resources for dementia. The main reason alleged for underdiagnosis is the limited effectiveness of drug therapy. CONCLUSIONS: This study underlines the importance of GPs' feeling of confidence when managing cognitively impaired patients with dementia, and the need of increasing training in the field of dementia, which could improve the awareness of GPs about diagnosis and available resources.

Prevalence and Co-Occurrence of Geriatric Syndromes in People Aged 75 Years and Older in France: Results From the Bordeaux Three-city Study.

BACKGROUND: Geriatric syndromes (GSs) are often the result of cumulative insults to multiple organ systems and are considered common in older adults. However, their frequency and co-occurrence are not well known in the elderly population. This study aimed to determine the prevalence of several GSs and to analyze the co-occurrence of these syndromes in a general population of elderly individuals. METHODS: A cross-sectional analysis of 630 adults aged 75 years or older participating in the 10-year follow-up of the Bordeaux sample of the French Three-City Study was conducted. The following 10 GSs were assessed: physical frailty, dementia and cognitive impairment, depressive symptoms, polymedication, social isolation, thinness, falls, dependence, sensory deficit, and incontinence. The prevalence of the 10 GSs was estimated, and multiple correspondence analysis (MCA) models were used to explore the mutual associations between these GSs. RESULTS: The mean age of the participants was 83.3 years; 69% were women, and 80.5% [95% confidence interval (CI) = 76.3-82.7] had at least one GS. The most frequent GSs were polymedication (50.6% 95%CI = 46.7-54.5) and falls (43.1% 95%CI = 38.4-46.1). The MCA models identified two major dimensions of the 10 GSs: "Dementia-Dependence-Incontinence" and "Frailty-Depression-Isolation." CONCLUSIONS: GSs were very common in this French elderly population and were grouped into two major dimensions: the "Dementia-Dependence-Incontinence" and "Frailty-Depression-Isolation."

Study Design and Rationale of "A Multicenter, Open-Labeled, Randomized Controlled Trial Comparing MIdazolam Versus MOrphine in Acute Pulmonary Edema": MIMO Trial.

PURPOSE: Morphine has been used for several decades in cases of acute pulmonary edema (APE) due to the anxiolytic and vasodilatory properties of the drug. The non-specific depression of the central nervous system is probably the most significant factor for the changes in hemodynamics in APE. Retrospective studies have shown both negative and neutral effects in patients with APE and therefore some authors have suggested benzodiazepines as an alternative treatment. The use of intravenous morphine in the treatment of APE remains controversial. METHODS: The MIdazolan versus MOrphine in APE trial (MIMO) is a multicenter, prospective, open-label, randomized study designed to evaluate the efficacy and safety of morphine in patients with APE. The MIMO trial will evaluate as a primary endpoint whether intravenous morphine administration improves clinical outcomes defined as in-hospital mortality. Secondary endpoint evaluation will be mechanical ventilation, cardiopulmonary resuscitation, intensive care unit admission rate, intensive care unit length of stay, and hospitalization length. CONCLUSIONS: In the emergency department, morphine is still used for APE in spite of poor scientific background data. The data from the MIMO trial will establish the effect-and especially the risk-when using morphine for APE.