As I write this summer edition of the AGEC newsletter, I am thrilled to let you know that we have successfully written for and received a new HRSA grant award for the AGEC for the next 5 years beginning July of 2024. I will highlight the new grant components in my fall Director’s Letter to you, but for now I will end this current grant with a final note about the 4M’s Age-Friendly framework.

First, I want to first thank you all for reading last year’s articles here regarding the 4M’s of age-friendly care in general. I enjoyed writing those and being able to discuss those concepts in a framework that embraces older adults and puts what Matters to them in the very center of their care.

This quarter, I just want to let you know that the 4M’s framework has also been translated to include environments outside of just the primary care clinical visit or acute care hospital stay. Research has been completed on the application of these concepts to nursing home residents, surgical hospitals, emergency departments, and convenient or urgent care clinics. There are also guides to help with implementation to each of these settings as well as implementation guides to assist with the implementation or incorporation of the concepts into electronic health records. There are also videos, workbooks, case studies, and media assistance available. The link below is the general link to the IHI’s plethora of resources on the 4M’s framework. It is free to use!

Thank you for reading and if you need information about the 4M’s, please contact us at the AGEC. I look forward to telling each of you all about our new grant in our Fall newsletter! Until then, stay cool and hydrated this summer and have some fun!!

https://www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/Resources.aspx

Currently, 17.3% of the United States population is 65 years and older (United States Census Bureau, 2022). By 2030, all baby boomers will be older than 65 representing an older population where one of every five will be retirement age (United States Census Bureau, 2018). As this population grows, so too will the need for surgeries and surgical procedures requiring anesthesia.

Postoperative Delirium

While anesthesia delivery is safer today than ever before, the older population presents some unique challenges that require vigilance and careful planning to prevent unwanted outcomes. Several neurocognitive disorders are potential issues during the postoperative period. The most common of these disorders, and the focus of this article, is postoperative delirium (POD). Post-operative delirium can happen in approximately 65% of older individuals and is characterized by postoperative inattention, confusion (Gabrielli et al., 2019), fluctuating courses of consciousness, and altered perceptions of reality which are not explained by a preoperative diagnosis of dementia (Lin et al., 2018). The cause of POD is not known. It is thought to be caused by a central cholinergic deficiency brought about by a combination of anticholinergic medications given during anesthesia, potential hypoxic brain injury while in the perioperative phase, and systemic inflammation from the surgery which releases a chemical cascade that further impairs cognition. If the patient is cognitively impaired preoperatively, they will not have the cognitive reserve to maintain homeostasis, and clinical delirium will ensue leading to long-term sequela (Lin et al, 2018).

The Assessment

An efficient preoperative assessment is required to determine if the older patient is at risk of POD. Anesthesia providers are accustomed to performing a quick anesthesia, pulmonary, and cardiovascular assessment on the patient and then a specific assessment based on the surgical procedure. Assessments for POD can take more time than the anesthesia provider can provide, however, at some point before the patient’s surgery, there needs to be an assessment of the patient’s cognitive ability and their risk of POD. There are screening tools available such as the confusion assessment method (CAM) which assesses four domains of POD: acute onset and fluctuating courses, inattention, disorganized thoughts, and altered levels of thinking (Alghamdi et al., 2023). This assessment can be completed upon the patient’s admission and alert the anesthesia provider of the need to develop an anesthesia plan that incorporates appropriate steps to decrease the potential for POD.   

Risk Factors and Complications of POD

It is important to note that POD can be divided into two factors: predisposing and precipitating. Predisposing are those cognitive factors that the patient has upon admission, their baseline cognition. Precipitating factors are those that may cause POD during the perioperative period and may be able to be reversed (Gabrielli et al., 2019).

There are many risk factors for POD. The American Geriatric Society (AGS) guidelines suggest that a preoperative risk factor assessment should include five predisposing elements: age greater than 65, severe illness, infection, chronic cognitive decline or dementia, and poor vision or hearing. As a note of interest, a pre-existing impairment of cognition can cause the patient to have delirium in the week following surgery (Gabrielli et al., 2019). Other predisposing risk factors for POD include renal failure, male gender, and previous CVA (Lin et al., 2018).  There are many precipitating factors for POD as well. Precipitating factors include: duration, invasiveness, and urgency of the surgery, ICU admission, postoperative complications (Gabrielli et al., 2019), hypoxia, electrolyte imbalance (Almuzayyen et al., 2023), polypharmacy, ASA score >2, and intraoperative blood loss (Lin et al., 2018).  

             

Complications of POD are numerous and include increased dependence on caregivers, decreased quality of life, increased mortality (Lin et al., 2018), exacerbation of cognitive diseases, whether diagnosed or undiagnosed, such as Alzheimer’s, dementia, and other neurodegenerative diseases (Alghamdi et al., 2023). For those patients > 65 years old, cognitive decline can be an issue post-operatively for up to 3-6 months and some patients may not return to cognitive baseline a year postoperatively (Gabrielli et al., 2019). Taking the risk factors and the postoperative complications into consideration, it is extremely important for the anesthesia provider to provide the safest anesthetic for this population.

Anesthesia Management

The anesthetic management focuses primarily on both predisposing and precipitating risk factors for POD and the prevention of poor outcomes. Age-adjusted anesthetic dosing should be considered in this population. As adults grow older, the dose requirement for anesthetic medications and gas decreases significantly. It is postulated that anesthetic drugs contribute to POD either through neurotoxicity, neuroinflammation, or indirectly by physiologic alterations in the blood-brain barrier (Gabrielli et al., 2019). However, there is no absolute consensus in the literature regarding the most appropriate anesthesia plan to prevent POD.

It has been generally held by some anesthesia providers that regional anesthesia is better than general anesthesia for this population. However, a 2022 systematic review of 8 randomized controlled trials (RCTs) (3,555 elderly patients) demonstrated no significant difference between general and regional anesthesia regarding POD. In 2021, a systematic review and meta-analysis of 15 RCTs comparing the use of propofol versus inhaled gas (184 elderly patients) did show low-quality evidence that propofol was superior over inhaled gas. However, since an EEG was also used, it was determined it was more likely the depth of anesthesia as monitored by the EEG than by the propofol (Almuzayyen et al., 2023).

With moderate quality evidence a 2018 Cochrane systematic review demonstrated that using EEG indices along with auditory evoked potential could reduce the risk of POD measured 3- months postoperatively in patients 60 years and older. In addition, the Cognitive Dysfunction after Anesthesia Trial demonstrated using a bispectral index-guided (BIS) optimization of anesthetic depth prevented POD in 83 patients out of every 1000. This is the best evidence seen in the literature thus far.

Multiple trials with various medications have shown mixed results. Intraoperative dexmedetomidine, a non-opioid alpha-2 agonist, produced different results in three studies. It demonstrated a decrease in POD after orthopedic surgeries, but no difference in two other cardiac and non-cardiac studies. However, a systematic review completed on these three studies did a subgroup analysis and found it may have decreased POD (Gabrielli, 2019). Ketamine, Clonidine, Melatonin, and Tryptophan have all had either poor, mixed, or no effect on POD. Gabrielli (2019) suggests that so many negative medication trial studies raise the question of the need to understand the pathophysiology of POD so a way to disrupt the mechanism within the processes can be learned.

What Can Be Done?

More research needs to be done to understand and treat or prevent POD. The literature does produce evidence that some anesthesia therapies work in some instances, however, not all are feasible for every facility. For example, EEG readings show the depth of anesthesia and make it easier to avoid the anesthetic being too deep. However, there are not enough EEG machines for every OR room, it is time-consuming to place the electrodes and they have to be placed by a specialty-trained provider. It would also slow down OR room turnover which is expensive. The BIS monitor is more user-friendly, but not all facilities have the equipment and it is costly, especially for rural hospitals. Medications that are generally used such as ketamine and dexmedetomidine are controversial at best in the treatment or prevention of POD.

A hospital-wide program called The Hospital Elder Life Program (HELP) employs a multidisciplinary approach to prevent cognitive and functional decline in hospitalized patients. This program includes assistance with nutrition, social support, cognitive orientation, initiation of a sleep protocol, patient mobilization, and healthcare staff education (Vlisides & Avidan, 2019). A meta-analysis of 14 studies of this program demonstrated a significant decrease in delirium incidence, falls, and healthcare costs. While other study results are inconclusive or mixed, thus far, this one is showing reproducible results in preventing delirium (Vlisides & Avidan, 2019).  

Until more research is completed on the pathophysiology of POD, anesthesia providers will continue to treat POD as they have in the past using anecdotal evidence and best-known practice. There is not a lack of research finding treatments for POD, but there is a lack of research on finding the causes of POD.           

References

Alghamdi AS, Almuzayyen H, Chowdhury T. (2023). The elderly in the post-anesthesia care unit. Saudi J Anaesth. 17(4):540-549. doi: 10.4103/sja.sja_528_23. Epub 2023 Aug 18. PMID: 37779571; PMCID: PMC10540998.

Almuzayyen HA, Chowdhury T, Alghamdi AS. (2023). Postoperative cognitive recovery and prevention of postoperative cognitive complications in the elderly patient. Saudi J Anaesth. 17(4):550-556. doi: 10.4103/sja.sja_529_23.

Lin HS, McBride RL, Hubbard RE. (2018). Frailty and anesthesia - risks during and post-surgery. Local Reg Anesth. 11:61-73. doi: 10.2147/LRA.S142996. PMID: 30323657; PMCID: PMC6178933.

Mahanna-Gabrielli E, Schenning KJ, Eriksson LI, Browndyke JN, Wright CB, Culley DJ, Evered L, Scott DA, Wang NY, Brown CH 4th, Oh E, Purdon P, Inouye S, Berger M, Whittington RA, Price CC, Deiner S. (2019).  State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 8. Br J Anaesth. 123(4):464-478. doi: 10.1016/j.bja.2019.07.004.

Staheli B, Rondeau B. Anesthetic Considerations in the Geriatric Population. [Updated 2023 Aug 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK572137/

United States Census Bureau. (2018). Older people projected to outnumber children for the first time in the u.s. history. https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html

United States Census Bureau. (2022). Search: United states 65 years and older in the united states. https://www.census.gov/search-results.html?searchType=web&cssp=SERP&q=Older%20Population

Vlisides, P., Avidan, M. (019). Recent advances in preventing and managing postoperative delirium. F1000Research 8(607). 1-10. f1000research-8-18345.pdf (nih.gov)

Wang C, Tan B, Qian Q. (2023). The impact of perioperative enhanced recovery nursing model on postoperative delirium and rehabilitation quality in elderly patients with femoral neck fractures. BMC Musculoskelet Disord.6;24(1):947. doi: 10.1186/s12891-023-07068-4. PMID: 38057753; PMCID: PMC10702044.          

By: Laura Spradley, MS, CDP, AGEC

Michael Anders, PhD, Educational Development UAMS, and

Leah Greenfield, Executive Director LifeQuest of Arkansas

Loneliness, as defined in the 2023 U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community (1), is a subjective distressing experience that results from perceived isolation or inadequate meaningful connections, where inadequate refers to the discrepancy or unmet need between an individual’s preferred and actual experience. (2,3) A report from the National Academies of Sciences, Engineering, and Medicine (NASEM) points out that more than one-third of adults aged 45 and older feel lonely, and nearly one-fourth of adults aged 65 and older are considered to be socially isolated. (2) Loneliness and social isolation in older adults are serious public health risks affecting a significant number of people in the United States and putting them at risk for dementia and other serious medical conditions. (4)

A goal of the Arkansas Geriatric Education Collaborative (AGEC) (a HRSA-supported GWEP grant) is to deliver community-based programs that improve health outcomes and quality of care for older adults. One program, through which this goal is reached, is provided through an education collaboration with AGEC and LifeQuest of Arkansas (LifeQuest). LifeQuest provides social connectedness and educational programs through lectures, art classes, and physical exercise programs to older adults (50+yrs.) throughout Arkansas. LifeQuest is based on an open-university concept with no homework, tests, or grades. Programs are offered online and in-person with lectures/discussions and hands-on classes on a variety of topics for an average of 4-6 weeks per session.

Both AGEC and LifeQuest were interested in evaluating three dimensions of loneliness: relational connectedness, social connectedness, and self-perceived isolation, and to determine over time, changes in loneliness of first-time participants enrolled into the LifeQuest program. First-time enrollees to LifeQuest, who elected to participate, were contacted for a telephone survey utilizing the UCLA 3-Item Loneliness Scale, prior to attending their first program at LifeQuest. Participants were contacted again 3 months later, since loneliness can be a “snapshot” at any given time, to see if participation in the life-long learning programs offered at LifeQuest, improved in any (or all) areas of loneliness.

Our findings, in Table 2, comparing “pre LifeQuest”, and “post LifeQuest,” show there was a significant decrease in the feeling of lacking companionship (p-value = .046), and the magnitude of effect size was large (.60). There was no difference in pre, and post comparison of feeling left out and feeling isolated from others. Although participant numbers are small, it is encouraging for all involved to see that a program, such as LifeQuest of Arkansas, can help in making a difference in loneliness in the lives of older adults! 

References

1.     Our Epidemic of Loneliness and Isolation: 2023 The U.S. Surgeon General’s Advisory on the Healing Effects of Social Connection and Community. Washington, D.C.  https://www.hhs.gov/sites/default/files/surgeon-general-social-connection-advisory.pdf

2.   National Academies of Sciences, Engineering, and Medicine. 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663.

3.    Prohaska T, Burholt V, Burns A, et al. Consensus statement: loneliness in older adults, the 21st century social determinant of health? BMJ Open. 2020;10(8):e034967.

4.   Loneliness and Social Isolation Linked to Serious Health Conditions, April 29, 2021Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion https://www.cdc.gov/aging/publications/features/lonely-older-adults.html

Both sleep and exercise are important factors in sustaining optimal health, and there are a number of research studies that suggest that regular moderate exercise can improve sleep (1). However, when making sleep hygiene recommendations (behaviors and environment changes meant to improve sleep duration and quality), people are often warned against exercising too close to bedtime. Because both sleep and exercise are important, but it’s often hard to find sufficient time to do both, a busy person may face a dilemma at the end of their day: “Should I forgo exercise and its benefits to sleep, or should I get my exercise done even if it is close to my bedtime and risk disrupting my sleep?”

Although conventional sleep hygiene advice is to avoid exercise within one hour of bedtime, there is some research work suggesting this advice may be too conservative. Bryson and Mastin (2) found pre-sleep exercise could not significantly predict either clinically relevant daytime sleepiness or sleep quality. A systematic review and meta-analytic study found no support for the idea that exercise negatively affects sleep when studies on exercise within four hours of bedtime are included (3). What then should we tell people about exercise and sleep? We set out to determine if age might be an important variable to consider when giving advice about exercising before bed.

About the participants

A large sample of over 2000 participants, most of whom were living in Arkansas when the data were collected, were included. Ten percent were over the age of 40 (1668 were traditional college-age 18 – 23 years, 219 younger adults 24 – 39 years, and 199 older adults 40 – 85 years), 51.2% identified as White/Non-Hispanic, and 68.6% identified as female. We examined the relationship between pre-sleep exercise and sleepiness across different age groups by asking participants to indicate how often they exercise to the point of sweating within one hour of going to bed (1 = Never, 2 = Rarely, 3 = Sometimes, 4 = Frequently, 5 = Always). And collecting subjective sleep and sleepiness measures using the Epworth Sleepiness Scale (a simple 8-item questionnaire with scores from 0 – 24 producing higher scores for greater sleepiness) and the Pittsburg Sleep Quality Index (PSQI), which produces seven component scales, one of which is identified as daytime dysfunction (scores from 0 = no difficulty - 3 severe difficulty) representing feelings of sleepiness interfering with your day.

What they told us

Regularly exercising before bed is uncommon regardless of age. Only 3% of traditional-age college students, 0.2% of younger adults, and <0.1% of older adults reported exercising close to bed frequently or always. And although uncommon in both groups, traditional-age college students were significantly more likely to engage in exercise close to bed (M = 1.58, SD = 0.85) than older adults (M = 1.36, SD = 0.75).

For the entire group, exercising close to bed was not meaningfully related to sleepiness: The correlation between exercise and sleepiness and sleep quality measures was extremely small when we looked at everyone together. No r-square value even reached 1%. What that means is that less than 1% of the differences seen in daytime sleepiness scores across individuals could be predicted by knowing how often someone is exercising close to their bedtime. Another way to say that is when looking at everyone at the same time, exercising close to bed was not related to sleepiness.

But does age make a difference for this relationship? Although there was not a meaningful relationship between exercise and sleepiness for everyone together, when we separated age groups, we found something important. For people over the age of 40, the more frequently they exercised close to bed, the sleepier they were (presumably, that exercise close to going to bed was disrupting their sleep which in turn led to daytime sleepiness). This relationship was very strong, with 24% of the differences in sleepiness in this group of older adults being predicted by their frequency of exercising within one hour of bed. This was not the case for either group of our younger participants (traditional-age college students or younger adults <40 years; See Figure 1).



Summary: Exercise is important for health in many ways and is recommended for good nighttime sleep. For younger people (<40 years) who find that fitting exercise in close to their bedtime is their only option, this may actually be ok for most. However, for older adults, trying to find space for exercise earlier in the day rather than before bed, is likely to be important for getting the sleep benefits that exercise can afford.

Figure 1:

References



1) Buman, M.P. & King, A.C. (2010). Exercise as a treatment to enhance sleep. American Journal of Lifestyle Medicine, 4(6), 500-514. doi:10.1177/1559827610375532

2) Bryson, W. J., & Mastin, D. F. (2013). Sleep hygiene predictors of excessive daytime sleepiness and poor subjective sleep quality. Journal of Psychological Practice, 18, 88-104.

3) Stutz, J., Eiholzer, R., & Spengler, C. M. (2019). Effects of evening exercise on sleep in healthy participants: A systematic review and meta-analysis. Sports Medicine, 49(2), 269–287. https://doi.org/10.1007/s40279-018-1015-0