Neurocognitive Impairment Linked to Worse Outcomes after TJA
Total joint arthroplasty (TJA) patients with undiagnosed neurocognitive deficits are undergoing hip and knee replacement procedures at high rates and are more likely to have poorer short-term outcomes after surgery, according to new research led by orthopedic surgeons at NYU Langone Health.
The study of patients who were screened with cognitive assessments prior to TJA showed that those who scored worse on the tests were significantly more likely to fail to progress in rehabilitation and to require admission into the intensive care unit (ICU).
“Our data suggest that neurocognitive impairment is highly prevalent in older individuals who are set to undergo total joint replacements, and we suspect that rates may be underestimated nationwide,” said James Slover, MD, an associate professor of orthopedic surgery at NYU School of Medicine and an attending orthopedic surgeon and clinical site chief at NYU Langone Orthopedic Hospital.
“These patients required more hospital resources and progressed more slowly with physical therapy after surgery. Therefore, it is critical that strategies are developed to screen these patients and protocols are put in place to allocate more support to them before and after surgery.”
The research is being presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons (AAOS). It was also published in the February 2018 issue of the Journal of Arthroplasty.
Previous research has suggested that neurocognitive impairment before any major surgery may raise the risk for increased complications and worse outcomes, but this phenomenon has not been well-studied in patients undergoing TJA. More than 645,000 people undergo a total knee arthroplasty (TKA) and more than 306,000 undergo a total hip arthroplasty (THA) annually, according to the AAOS.
Dr. Slover and colleagues prospectively screened for neurocognitive impairment in more than 100 patients who were set to undergo TJA at NYU Langone Orthopedic Hospital. They used 3 validated cognitive tests: a grooved pegboard test for dexterity and coordination for both a dominant and non-dominant hand and an auditory verbal learning test for memory function.
Ninety-nine patients completed all screening tests before undergoing TJA and were followed for at least 1 year. Patients with previously diagnosed neurocognitive conditions, including Alzheimer’s and other dementias, were excluded from the study.
The researchers found that 53% of patients (53 of 99) had neurocognitive deficits identified on at least 1 of the 3 tests. There was a significant prevalence of neurocognitive impairment in patients between ages 50 and 59 (59%; 20 of 34 patients screened), although the highest proportion was reported in patients age 70 or older (62%; 13 of 21 patients screened). Depression was linked to higher likelihood of worse neurocognitive scores, with 77% of patients (13 of 17) with depression testing positive for neurocognitive impairment on any test, versus 48% of non-depressed patients (38 of 79).
Among patients with neurocognitive impairment, statistically significant differences were noted: 48% required ICU admission and medical response team consults and 64% had failures to progress in physical therapy, compared with 14% and 17% of controls, respectively. These patients also trended toward needing longer length of stays and were more likely to be readmitted to the hospital within 30 days or 1 year of the procedure, but the findings were not statistically significant.
Future research will focus on developing pre- and postsurgical evaluations and interventions to improve the outcomes of these patients, and larger studies are planned.
“If we identify patients with neurocognitive impairment prior to a joint replacement, our surgical care team can plan better and concentrate postoperative resources accordingly to make sure we are doing all we can to ensure the best outcomes,” Dr. Slover said.
Yu S, Eduse E, Kim K, Karia R, Slover J. Neurocognitive Dysfunction in Patients undergoing Total Joint Arthroplasty (Poster P0536). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.
Edusei E, Kim KY, Anoushiravani AA,, Yu S, Steiger D, Slover JD. Prevalence of neurocognitive dysfunction and its effects on postoperative outcomes in total joint arthroplasty. J Arthroplasty. 2018;33(2)350-4.