术前认知功能障碍与术后不良结局的关系

随着老年化的到来及医疗水平的提高，越来越多的老年患者需要行择期手术。而老年人群中认知功能障碍的比例不低，且整体数量逐渐加大。目前术前评估基本以心肺肝肾等功能评估为主，极少涉及脑功能评估，术前认知功能障碍与术后结局的关系如何尚缺乏系统的研究，在下面这篇通讯中作者通过前瞻性队列研究的形式探讨老年患者术前认知功能障碍与术后不良结局的关系，结果如何呢？详见下文！

老年患者术前认知障碍与术后不良结局关系的前瞻性队列研究

近年来，以认知状态为主要反映的术前脑功能日益受到重视。在一项前瞻性观察性研究中，术前中重度认知功能障碍的患者，在股骨颈骨折后，不能行走、再次手术、1年死亡率和生活质量下降的发生率较高[5]。另一项研究表明，术前MiniCog评分≤2（认知障碍）的全膝或髋关节置换术（TKA或THA）的老年患者发生术后谵妄及住院时间更长的几率更大[1]。然而，这些研究只关注短期结果。因此，该研究旨在探讨接受TKA或THA的老年患者术前认知功能障碍与长期临床结局之间的关系。

该研究由南京大学金陵医院伦理委员会批准（临床试验注册号：NCT03143595）。纳入标准：2013年4月12日至2013年8月8日在金陵医院接受择期TKA或THA治疗的年龄≥65岁的患者。排除标准包括那些不愿意参加的人、有严重听力或视力障碍的人、已经参加其他临床试验的人。在我们的研究中，共有患者217名入组并签署了知情同意书，这些患者根据术前24小时简易精神状态检测量表（Mini-MentalState Examination，MMSE）测试结果被分为认知功能障碍组（n=61）和认知功能正常组（n=156）。临床结局包括：住院天数、术后并发症、5年生存率。

该研究观察到：与认知正常组患者相比，认知障碍组患者住院天数更长，术后谵妄发生率更高，5年生存率更低（表一）。

该研究确认了早期研究的结果：在择期行TKA或THA的老年患者中，术前认知障碍与术后不良结局相关。因此常规认知功能筛查对于手术患者，特别是老年患者可能是必须的。

※※※※※※原文 ※※※※※※

Adversepostoperative outcomes in elderly patients with preoperative cognitiveimpairment: A prospective cohort study

Asthe population ages, approximately one-third of elective surgical proceduresare performed on elderly patients [1]. These patients represent a high-riskgroup of adults which are associated with increased adverse outcomes includingincreased postoperative complications and mortality [2]. Preoperative riskassessment is important to predict the postoperative outcomes, especially forthe elderly [3,4]. Many organs such as cardiac, pulmonary, renal and hepatichave been evaluated routinely as a part of preoperative risk assessment, yetthe role of preoperative brain function assessment remains less well studied.

Recently,preoperative brain function mostly reflected by cognitive status is receivingincreasingly attention. In a prospective observational study, patients withmoderate to severe preoperative cognitive impairment are associated with higherincidence of becoming non-walker, reoperation, and 1-year mortality anddecreased quality of life after femoral neck fracture [5]. Another study hasshowed that patients with a MiniCog score ≤2 (cognitive impairment) before surgery were more likely to developpostoperative delirium and had a longer hospital length of stay in elderly patientsscheduled for total knee or hip arthroplasty (TKA or THA) [1]. However, thesestudies only focused on short-term outcomes. Therefore, we designed this studyto explore the association between preoperative cognitive impairment andlong-term clinical outcomes in older patients undergoing TKA or THA.

Thepresent study was approved by the Institutional Ethics Committee of JinlingHospital of Nanjing University, Nanjing (Clinical trials. gov; registrationnumber NCT03143595). Inclusion criteria include patients aged ≥65years undergoing elective TKA or THA in Jinling Hospital between April 12, 2013and August 8, 2013. Exclusion criteria include those unwilling to participate,the presence of serious hearing or vision loss, and concurrent enrollment in anotherclinical study. In our study, 217 patients were enrolled and written informed consentwas obtained from all participants or representative prior testing. Patientswere divided into impaired cognition group (n = 61) and normal cognition group(n = 156) according to baseline cognition assessed by the mini-mental stateexamination 24 h before surgery. Clinical outcomes included length of stay,postoperative complications, and 5-year survival rate.

Weobserved that the length of stay in the impaired cognition group is prolongedcompared with the normal cognition group. In addition, patients in the impairedcognition group show higher incidence of postoperative delirium than that inthe normal cognition group. The 5-year survival rate in the impaired cognitiongroup is significantly lower than their normal counterparts (Table 1).

Ourstudy confirms previous findings that preoperative cognitive impairment isassociated with adverse outcomes in elderly patients undergoing elective THA or THA（原文如此，小麻哥认为应该是TKA or THA）. Thus, routine screening for cognitive performance may be necessary forsurgical patients especially for the elderly.