Canadian Researchers Find ‘Silent’ Strokes Common after Surgery, Linked to Cognitive Decline

Canadian researchers have discovered that covert – or ‘silent’ – strokes are common in seniors after they have elective, non-cardiac surgery and double their risk of cognitive decline one year later.

While an overt stroke causes obvious symptoms, such as weakness in one arm or speech problems that last more than a day, a covert stroke is not obvious except on brain scans, such as MRI. Each year, approximately 0.5 per cent of the 50 million people age 65 years or greater worldwide who have major, non-cardiac surgery will suffer an overt stroke, but until now little was known about the incidence or impacts of silent stroke after surgery.

The results of the NeuroVISION study were published in The Lancet.

“We’ve found that ‘silent’ covert strokes are actually more common than overt strokes in people aged 65 or older who have surgery,” said PJ Devereaux, co-principal investigator of the NeuroVISION study. Devereaux is a cardiologist at Hamilton Health Sciences (HHS), professor in the departments of health research methods, evidence, and impact, and medicine at McMaster, and a senior scientist at the Population Health Research Institute of McMaster University and HHS.

Devereaux and his team found that one in 14 people over age 65 who had elective, non-cardiac surgery had a silent stroke, suggesting that as many as three million people in this age category globally suffer a covert stroke after surgery each year.

NeuroVISION involved 1,114 patients aged 65 years and older from 12 centres in North and South America, Asia, New Zealand, and Europe. All patients received an MRI within nine days of their surgery to look for imaging evidence of silent stroke. The research team followed patients for one year after their surgery to assess their cognitive capabilities. They found that people who had a silent stroke after surgery were more likely to experience cognitive decline, perioperative delirium, overt stroke or transient ischaemic attack within one year, compared to patients who did not have a silent stroke.

“Over the last century, surgery has greatly improved the health and the quality of life of patients around the world,” said Marko Mrkobrada, an associate professor of medicine at University of Western Ontario and co-principal investigator for the NeuroVISION study. “Surgeons are now able to operate on older and sicker patients thanks to improvements in surgical and anesthetic techniques. Despite the benefits of surgery, we also need to understand the risks.”

“Vascular brain injuries, both overt and covert, are more frequently being detected, recognized and prevented through research funded by our Institute and CIHR,” said Brian Rowe, scientific director of the Institute of Circulatory and Respiratory Health, Canadian Institutes of Health Research (CIHR). “The NeuroVISION Study provides important insights into the development of vascular brain injury after surgery, and adds to the mounting evidence of the importance of vascular health on cognitive decline. The results of NeuroVISION are important and represent a meaningful discovery that will facilitate tackling the issue of cognitive decline after surgery.”

Source: McMaster University


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Physical And Mental Exercise Lower Chances For Developing Delirium After Surgery


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After having surgery, many older adults develop delirium, the medical term for sudden and severe confusion. In fact, between 10 and 67 percent of older adults experience delirium after surgery for non-heart-related issues, while 5 to 61 percent experience delirium after orthopedic surgery (surgery dealing with the bones and muscles).

Delirium can lead to problems with thinking and decision-making. It can also make it difficult to be mobile and perform daily functions and can increase the risk for illness and death. Because adults over age 65 undergo more than 18 million surgeries each year, delirium can have a huge impact personally, as well as for families and our communities.

Healthcare providers can use several tools to reduce the chances older adults will develop delirium. Providers can meet with a geriatrician before surgery, review prescribed medications, and make sure glasses and hearing aids are made available after surgery (since difficulty seeing or hearing can contribute to confusion). However, preventing delirium prior to surgery may be the best way to help older adults avoid it.

A team of researchers from Albert Einstein College of Medicine designed a study to see whether older adults who are physically active before having surgery had less delirium after surgery. The research team had previously found that people who enjoy activities such as reading, doing puzzles, or playing games experienced lower rates of delirium. The team published new findings on physical activity in the Journal of the American Geriatrics Society.

The researchers noted that several studies have shown that exercise and physical activity may reduce the risks of developing dementia (another medical condition affecting mental health, usually marked by memory problems, personality changes, and poor thinking ability). What’s more, earlier studies have shown that regular exercise can lower the risk of developing delirium by 28 percent.

The participants in this study were adults over 60 years old who were undergoing elective orthopedic surgery. Most participants were around 70 years old. None had delirium, dementia, or severe hearing or vision problems.

The researchers asked participants the question “In the last month, how many days in a week did you participate in exercise or sport?” The researchers noted the type of physical activities the participants did, as well as whether and how often they read newspapers or books, knitted, played cards, board games, or computer games, used e-mail, sang, wrote, did crossword puzzles, played bingo, or participated in group meetings.

The participants said their physical exercise included walking, taking part in physical therapy, lifting weights, cycling, stretching, engaging in competitive sports, and dancing. The most commonly reported activity was walking. Though most participants were only active one day a week, nearly 26 percent were active five to six days a week and 31 percent were active five to seven days a week.

Of the 132 participants, 41 (31 percent) developed postoperative delirium.

The researchers reported that participants who were physically active six to seven days a week had a 73 percent lower chance of experiencing postoperative delirium (delirium that develops after surgery). They also reported that being mentally active was a strong factor in reducing chances of developing postoperative delirium. Participants who regularly read newspapers or books, knitted, played games, used e-mail, sang, wrote, worked crossword puzzles, played bingo, or participated in group meetings had an 81 percent lower chance of developing postoperative delirium.

“While our study was preliminary in nature, we found that modest regular physical activity, as well as performing stimulating mental activities, were associated with lower rates of delirium after surgery,” said the researchers. The researchers also found that physical and cognitive activities seemed to offer benefits independent of each other. This suggests that people with activity-limiting injuries or conditions can still benefit from being mentally active, and people with mild cognitive impairment can still benefit from being physically active. The researchers noted that more research is needed to learn about the role of exercise and cognitive training in reducing delirium after surgery.

Source: HealthinAging


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Delirium Toolkit . . . . .

Should You Get Pills or Surgery for Atrial Fibrillation?

Many older Americans have the worrisome and potentially dangerous irregular heartbeat known as atrial fibrillation, or “a-fib,” and they’re typically offered medicines or a surgery called ablation to correct it.

Which works best?

Two new trials may have the answer. Researchers say ablation and medicines perform similarly in protecting a-fib patients from stroke, death and other complications.

However, ablation may beat out drug therapy over the long term, reducing recurrences of a-fib and related hospitalizations for years to come, researchers say.

Patients who got ablation — where a catheter is used to tweak the heart muscle cells responsible for the arrhythmia — also seemed to have less shortness of breath, less fatigue and all-around better quality of life five years later, compared to those who got drug therapy alone.

The quality-of-life trial, “because of its size and duration, provides extraordinary new data regarding the patient’s perspective,” said Dr. Yves Rosenberg.

He was program officer for the study, and is also chief of the Atherothrombosis and Coronary Artery Disease Branch at the U.S. National Heart, Lung, and Blood Institute (NHLBI), which helped fund both trials.

A cardiologist who reviewed the findings said the data should reassure patients.

“I think the takeaway from this study is that catheter ablation is effective and safe for treating atrial fibrillation,” said Dr. Laurence Epstein, who directs electrophysiology at Northwell Health in Manhasset, N.Y.

“If you have atrial fibrillation and are symptomatic, ablation is a reasonable first-line option, as opposed to taking drugs,” he said.

Treatment pros and cons

According to the NHLBI, a-fib affects at least 2.7 million Americans and can lead to stroke, heart failure, and even mental impairment. Symptoms include rapid heart palpitations (“flip-flops” or skips); fatigue; shortness of breath, and difficulty doing physical activity.

“Since current drug therapies often have limited effectiveness in controlling atrial fibrillation, it is very important to understand whether ablation, an invasive procedure, yields better outcomes,” Dr. David Goff, director in the division of cardiovascular sciences at the NHLBI, said in an institute news release.

As Epstein explained, during ablation, “long catheters — wires with electrodes on them — are placed into the heart via the large veins in the groin. Radio waves are delivered from the catheter to the heart muscle, which causes heat and the controlled destruction of the muscle cells responsible for causing atrial fibrillation.”

Sometimes ablation is performed using tiny balloons that freeze the heart muscle to create the same effect.

Of course, no treatment is foolproof. “Depending on the patient the procedure can be as effective as 80-90 percent,” Epstein said, “but in others, at best, 50 percent.”

Many other patients get drug therapy alone to control the aberrant heart rhythm. But Epstein said outcomes are often “disappointing because the drugs do not work that well and that they can cause ‘pro-arrhythmia.’

“Pro-arrhythmia is when a drug used to treat an abnormal heart rhythm can actually cause a worse, more dangerous heart rhythm,” he explained.

Long-term benefits

To settle the meds-versus-ablation debate, the NHLBI helped conduct these two trials, which included more than 2,200 patients treated at 126 sites in the United States, Canada, Asia and Europe.

Half the patients had ablation and half were put on drug therapy, but could have ablation if their a-fib symptoms could not be controlled with medication — something known as “intent to treat.”

In the end, about 27 percent of the patients who started on drug therapy did end up undergoing ablation.

The median follow-up of patients in the trial was about four years.

“While data from the trial did not show that ablation was superior to drug therapy in reducing rates of deaths and strokes, it showed reduced recurrence of atrial fibrillation, as well as reductions in hospitalizations,” Rosenberg said in the news release.

The researchers noted that the overall rate of deaths and strokes was lower than expected. Also, about 9 percent of the patients assigned to receive ablation did not, in the end, undergo the procedure.

So, “when we examined the data according to the treatment actually received, the ablation group had significantly lower rates of death as well as the combination of death, disabling stroke, serious bleeding, or cardiac arrest compared with patients who only received drug therapy,” said study principal investigator Dr. Douglas Packer. He’s a cardiologist and professor of medicine at Mayo Clinic in Rochester, Minn.

The research team found that 12 months after the start of treatment, both groups of patients had at least some improvement in their quality of life. However, those in the ablation group had a larger decline in symptoms such as fatigue and shortness of breath, and their boost in quality of life lasted through five years of follow-up.

At the start of the study, 86 percent of patients in the ablation group and 84 percent on drug therapy reported atrial fibrillation symptoms during the previous month. By the end of the study, only 25 percent of patients in the ablation arm and 35 percent of those on drugs only reported symptoms.

Patients with the most severe symptoms at the start of the study had much greater improvement after ablation than those who initially had mild symptoms, the researchers added.

Dr. Satjit Bhusri is a cardiologist at Lenox Hill Hospital in New York City. Reviewing the new data, he said that the trials give doctors and patients valuable guidance.

First of all, he said, if your a-fib isn’t so bad that it harms your quality of life, perhaps controlling it with medicines alone might work. However, when quality of life is affected, a move to ablation therapy may be warranted, Bhusri said.

For his part, Epstein believes “we certainly need to continue to study these findings. As technology continues to advance, and ablation procedures become safer and more effective, ablation will most certainly become the treatment of choice.”

The papers were published in the Journal of the American Medical Association.

Source : HealthDay

Study: Age Is Not A Risk Factor for Complications After Surgery Among Older Patients

Kelly O’Brien wrote . . . . . . . .

Among older patients, frailty and cognitive impairment before surgery are associated with developing complications after surgery, but age is not, a new study suggests.

In addition to frailty, depressive symptoms and smoking were also associated with developing postoperative complications following elective surgery, according to the systematic review, published online today in the journal BMC Medicine.

Researchers at St. Michael’s Hospital also found that a patient’s American Society of Anesthesiologists status, which evaluates the physical health of a patient before surgery and is traditionally assessed as a risk factor for postoperative complications, was not associated with postoperative complications in older patients.

“The fact that age and ASA status were not risk factors for postoperative complications is somewhat surprising, because these are the factors a clinician would typically look at when assessing a patient’s risk of developing complications after surgery,” said Dr. Jennifer Watt, lead author of the study.

The review examined 44 existing studies including more than 12,000 patients 60 years and older and reporting on postoperative outcomes including complications, postoperative mortality, length of hospitalization, functional decline and whether patients were discharged home or to another hospital or long-term care facility.

Due to significant differences in the design and reporting methods of the included studies, the authors were unable to report on the level of risk for specific postoperative complications, or their severity.

The researchers found that across all studies, 25 per cent of older patients experienced some complications following elective surgery.

“Older adults are a diverse group of patients whose risk of postoperative complications is not solely defined by their age, comorbidities or the type of surgical procedure they receive,” said Dr. Watt. “This study highlights how common postoperative complications are among older adults undergoing elective surgery, and the importance of geriatric syndromes, including frailty, in identifying older adults who may be at risk.”

The review did not examine why frailty was associated with negative outcomes following surgery, but the authors hypothesize that frailty and not older age was associated with postoperative complications because frailty represents a patient’s biological age as opposed to their chronological age.

The authors also noted that there are proven interventions for a number of the risk factors identified in the review. Interventions aimed at improving a patient’s nutrition, physical fitness and cognition have been found to improve frailty in older patients, and smoking cessation interventions before surgery have been associated with a lower risk of postoperative complications, according to the review.

“With this population, there is potential to intervene to improve outcomes following surgery by identifying and addressing risk factors before surgery, in particular with risk factors like smoking and depressive symptoms,” said Dr. Watt. “These factors could be targeted in the preoperative clinic, potentially leading to better outcomes for older adults undergoing elective surgery.”

Source: St. Michael’s Hospital


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New Research Questions the Effectiveness of Common Decompression Shoulder Surgery

The surgery is used to ease shoulder pain.

A British research team tracked outcomes for patients who underwent “decompression surgery” to treat shoulder impingement — a condition where a shoulder tendon rubs and catches in the joint.

In decompression surgery, a small area of bone and soft tissue in the shoulder joint is removed, opening up the joint to prevent the abrasion that happens when the arm is lifted.

All of the patients had suffered shoulder pain for at least three months despite nonsurgical approaches, including physiotherapy and steroid injections.

So, the patients were then sent to decompression surgery (90 patients), a placebo surgery where they thought they got the procedure but didn’t (94 patients), or no treatment (90 patients).

In the placebo surgery, the surgeons looked inside the joint but did not remove any tissue.

Both groups of surgery patients also had one to four physiotherapy sessions afterwards. Those in the no-treatment group had only a check-up three months after the start of the study.

Six to 12 months after entering the study, shoulder pain symptoms had eased in all three groups of patients, regardless of whether they got the surgery or not, noted a team led by Andrew Carr of the University of Oxford.

While patients in both the decompression and placebo surgery groups had slightly greater reductions in shoulder pain than those in the no-treatment group, the difference was small and not likely to have a noticeable effect, Carr’s team reported Nov. 20 in The Lancet.

In the United States, shoulder pain accounts for 4.5 million doctor visits each year and the new findings question the value of decompression surgery, the researchers said.

“Over the past three decades, patients with this form of shoulder pain and clinicians have accepted this surgery in the belief that it provides reliable relief of symptoms, and has low risk of adverse events and complications,” Carr said in a journal news release.

“However, the findings from our study suggest that surgery might not provide a clinically significant benefit over no treatment, and that there is no benefit of decompression over placebo surgery,” he added.

But two specialists in shoulder pain had differing views on the study.

Berend Schreurs works at Radboud University Medical Center in the Netherlands, and wrote an accompanying journal editorial on the study. He said, “Hopefully, these findings from a well-respected shoulder research group will change daily practice. The costs of surgery are high, and although the low occurrence of complications might suggest that the surgery is benign, there is no indication for surgery without possible gain.”

But a U.S.-based orthopedic surgeon took issue with the study’s design, and believes decompression surgery may still have real value.

Dr. Peter McCann directs orthopedic surgery at Lenox Health Greenwich Village in New York City. He said that the study is flawed in that all of the people who were sent to surgery were selected because they had severe cases that had already failed to improve after three months of drugs and/or physiotherapy.

The nonsurgical group were — by nature — not these tougher cases, so McCann believes the comparison between the two groups lacks balance.

“A more rational approach would be to compare these patients who fail nonoperative treatment and undergo surgical treatment with a similar group of patients who have failed nonoperative treatment [and are then] followed for an additional 6 months without surgical intervention,” he said.

“Only in comparing such groups can one determine if surgical intervention has benefit,” McCann said.

Source: HealthDay


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