The tip of the iceberg …

In this edition of World Journal of Surgery, Khalil et al. explore the impact of Alzheimer's Disease and related dementias (ADRDs) on textbook outcome (TO) following selected major surgeries (CABG, AAA repair, pneumonectomy, colectomy, and pancreatectomy) whether elective, urgent, or emergent.1 TO is a composite measure consisting of no immediate postoperative complications, no extended length of stay (<75th percentile), and no readmissions or mortality within 90 days. By exploring Medicare claims data, the authors demonstrate that ADRD patients more likely suffer postoperative complications, discharge to a skilled nursing facility, and death in the immediate postoperative period or within 3 years compared to propensity-matched counterparts. This paper investigates the impact of a range of cognitive dysfunctions on surgical outcomes. Indeed, the impact of dementia and related conditions on postoperative outcomes appears underexplored but impacts daily practice. For example, dementia is not included in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) calculator that uses 20 clinical risk factors to assess patient- and procedure-specific postoperative complication risk to guide decision-making and informed consent. Khalil et al. suggest that the absence of dementia inclusion in ACS NSQIP underestimates untoward outcome likelihood. Relatedly, the lack of Medicare claims data granularity establishes more questions than answers. Despite the in-depth analysis, it remains unclear whether their results equally apply to other procedures (e.g., hip arthroplasty, aortic valve replacement, etc.) or if the surgical approach impacts outcome (e.g., minimally invasive vs. open vs. endovascular). Furthermore, dementia's influence is presented in a binary—as opposed to an interactive—fashion and is not assessed by dementia severity. Importantly, frailty—a condition that may be as impactful as dementia—does not appear to be incorporated into the author's outcome assessment. These questions are relevant to help guide decision-making around surgery in the aging population as nearly half of all individuals over age 65 will require a surgical procedure.2 Even though Khalil et al.‘s inquiry focuses on the US population, their conclusions have profound global implications. Fifty-seven million people bear a dementia diagnosis globally and that prevalence is expected to triple by 2050.3 Crafting outcome predictions with fidelity helps shape patient and family or surrogate expectations and aids in establishing goal-concordant care. The authors identify a 19% 90-day ADRD patient mortality following major surgery versus 12% in propensity-matched non-ADRD patients. Based on the increased urgent surgery proportion in those with ADRDs, this mortality difference would likely be exacerbated without propensity matching. Understanding the relative risk that dementia imparts on outcomes should inform preoperative discussions regarding best- and worst-case outcomes. Dementia is anticipated to impede postoperative recovery due to increased delirium risk coupled with challenges in effectively participating in postoperative therapies. While dementia patients may be unable to render complex decisions, their ability to express preferences and values is often preserved even with moderate to severe disease.4 Understanding a patient's goals helps decision-makers weigh outcomes against risk. TOs are not the only ones that are relevant for patients, families, and surrogates. Some non-textbook outcomes may achieve a patient's goals even if accompanied by a complication. For example, a palliative procedure that sufficiently prolongs life and allows participation in a child's life event may be singularly important but would be negatively assessed when relying on a TO approach. Such discussions may be quite emotionally fraught when patients present for urgent or emergent care. Moreover, it may be difficult for surrogates to avoid conflating their desires for the patient with what the patient would want for themselves if they could participate in shared decision-making. The surgeon's role in guiding them along this pathway will be enhanced by studies inspired by Khalil et al.‘s data. In this study, more than half of ADRD patients presented urgently for major surgery. This frequency suggests that surgeons should possess the communication skills and ethics knowledge required to navigate complex goals of care discussions especially when other partners, such as palliative care medicine, are unavailable. Relatedly, one must be certain to utilize ethical pillars relevant for the patient, even if they are different than the ones embraced by the surgeon. This notion is relevant when caring for out of country visitors, immigrants, and medical tourists alike. For patients presenting for elective procedures, ADRD screening may influence preoperative risk stratification and the discussion of procedural advisability based on anticipated outcomes. Such a discussion should also forecast likely complications and how they might impact care, recovery, and achieving goal-concordant management. Similar to tumor boards for oncology patients, those with ADRD might benefit from a multiprofessional discussion prior to being offered surgery. This resource—a high-risk surgery committee—currently exists at Veterans Affairs Hospitals to evaluate medically comorbid or multimorbid patients. It serves as a platform to discuss alternatives to operative therapy in partnership with palliative care medicine, geriatrics, and related experts. From the healthcare system perspective, ADRD patients evidenced increased intensive care unit utilization, longer hospital length of stay, higher readmission rate, and higher operative expenditures. Thus, accurately identifying the patients who are least likely to benefit from surgery is a process in which healthcare systems should invest. Doing so prioritizes goal-concordant care and responsible resource utilization. Khalil et al. have shared a structured foray into the impact of dementia on a composite outcome following a narrow spectrum of major surgical procedures. The next step is to expand their work to other procedures while assessing interventions that can mitigate the untoward impact of dementia on postoperative outcomes. Pre-habilitation reduces postoperative mortality and discharge to a nonhome facility in medically comorbid patients.5 It is uncertain if such an approach could be modified to address cognitive fitness for surgery, but pharmacological and nonpharmacological interventions (i.e., exercise and cognitive training) appear to improve cognitive function in dementia patients.6 Additionally, post-procedural interventions, such as a post-ICU recovery clinic, may decrease the risk of readmission and perhaps mortality. Combined approaches—common for a variety of conditions—may make at least some forms of dementia a modifiable risk factor. Erin G. Dawson: Conceptualization; writing—original draft.