Preoperative Cognitive Impairment As a Predictor of
Postoperative Outcomes in a Collaborative Care Model
Kahli Zietlow, MD,* Shelley R. McDonald, DO, PhD,* Richard Sloane, MPH,
Sandhya Lagoo-Deenadayalan, MD, PhD,
and Mitchell T. Heﬂin, MD, MHS*
OBJECTIVES: To compare postoperative outcomes of
individuals with and without cognitive impairment
enrolled in the Perioperative Optimization of Senior
Health (POSH) program at Duke University, a comanage-
ment model involving surgery, anesthesia, and geriatrics.
DESIGN: Retrospective analysis of individuals enrolled in
a quality improvement program.
SETTING: Tertiary academic center.
PARTICIPANTS: Older adults undergoing surgery and
referred to POSH (N = 157).
MEASUREMENTS: Cognitive impairment was deﬁned as
a score less than 25 out of 30 (adjusted for education) on
the St. Louis University Mental Status (SLUMS) Examina-
tion. Median length of stay (LOS), mean number of post-
operative complications, rates of postoperative delirium
(POD, %), 30-day readmissions (%), and discharge to
home (%) were compared using bivariate analysis.
RESULTS: Seventy percent of participants met criteria for
cognitive impairment (mean SLUMS score 20.3 for those
with cognitive impairment and 27.7 for those without).
Participants with and without cognitive impairment did
not signiﬁcantly differ in demographic characteristics,
number of medications (including anticholinergics and
benzodiazepines), or burden of comorbidities. Participants
with and without cognitive impairment had similar LOS
(P = .99), cumulative number of complications (P = .70),
and 30-day readmission (P = .20). POD was more com-
mon in those with cognitive impairment (31% vs 24%),
but the difference was not signiﬁcant (P = .34). Partici-
pants without cognitive impairment had higher rates of
discharge to home (80.4% vs 65.1%, P = .05).
CONCLUSION: Older adults with and without cognitive
impairment referred to the POSH program fared similarly
on most postoperative outcomes. Individuals with
cognitive impairment may beneﬁt from perioperative geri-
atric comanagement. Questions remain regarding the valid-
ity of available measures of cognition in the preoperative
period. J Am Geriatr Soc 0:1–6, 2018.
Key words: cognitive impairment; older adults;
postoperative outcomes; co-management
pproximately one-third of elective surgical procedures
are performed on adults aged 65 and older, and this
population has a high burden of postsurgical morbidity
As the population ages, an increasing num-
ber of surgeries will be performed on these higher-risk
Traditional preoperative risk assessment
tools, such as the American Society of Anesthesiologists
(ASA) Physical Classiﬁcation System, focus on medical fac-
tors associated with risk of adverse postoperative out-
but such tools do not account for risk factors
unique to older adults such as malnourishment, impaired
mobility, cognitive impairment, and frailty. Geriatric-speci-
ﬁc risk stratiﬁcation models are better able to predict out-
comes in older adults.
A growing literature supports
incorporation of tools used for geriatric assessment as part
of the preoperative evaluation of older adults undergoing
The Perioperative Optimization of
Senior Health (POSH) program is an innovative care
model developed at Duke University that aims not only to
assess surgical risk in older adults accurately, but also to
improve clinical outcomes through early multidisciplinary
risk assessment and targeted interventions throughout the
Cognitive ability is one of the most important periop-
erative risk indicators, and the prevalence of mild cognitive
impairment (MCI) and dementia are expected to rise.
operative cognitive impairment, whether MCI or dementia,
has been linked to higher rates of postoperative delirium
which, in turn, has been associated with
greater morbidity and long-term declines in functional sta-
tus and cognition.
Despite these ﬁndings, the literature
From the *Division of Geriatrics, Department of Internal Medicine;
Center for Aging;
Division of Geriatric Behavioral Health, Department
of Psychiatry; and
Department of Surgery, Duke University Health
Systems, Durham, North Carolina.
Address correspondence to Kahli Zietlow, GRECC (182) VAMC, 508
Fulton Street, Durham, NC 27705. E-mail: firstname.lastname@example.org
JAGS 0:1–6, 2018
© 2018, Copyright the Authors
Journal compilation © 2018, The American Geriatrics Society 0002-8614/18/$15.00
BRIEF METHODOLOGICAL REPORT
period. J Am Geriatr Soc 66:584–589, 2018.
JAGS 66:584–589, 2018
2018, Copyright the Authors
2018, The American Geriatrics Society 0002-8614/18/$15.00