Speaking at the 2019 Society for Vascular Surgery (SVS) Vascular Annual Meeting (VAM; 12–15 June, National Harbor, USA), Samir Shah (Division of Vascular Surgery, Brigham and Women’s Hospital, Boston, USA) reported that patients with dementia have worse outcomes after vascular surgery than those without dementia. He added these findings should be used to counsel dementia patients and their carers “to achieve goal-concordant” care.
“Our investigation showed that dementia is an independent risk factor for poorer traditional and patient-centred outcomes,” Shah told Vascular News. “Specifically, our analyses included multivariable analyses that adjusted for demographic factors (e.g. age) as well as comorbidities.”
Shah stated at VAM that while dementia is associated with poorer outcomes, such as increased mortality, after other types of surgery, the effect of dementia on post-vascular surgery outcomes was unknown. He added that this lack of data was despite there being a high prevalence of dementia among patients undergoing vascular surgery.
To explore the link between dementia and post-vascular surgery outcomes, Shah and colleagues reviewed Medicare free-for-service claims data between January 2011 and December 2011. Of 210,918 in patients undergoing vascular surgery (first admission only), 27,920 had dementia. Dementia patients were older, more likely to be female, and more frequently had comorbidities (e.g. diabetes). Overall, the majority of patients lived in the community.
In terms of vascular procedure, dementia patients underwent significantly more emergent/urgent procedures than those without dementia (61% vs. 38%, respectively; p<0.001) but underwent significantly fewer high-risk procedures (18% vs. 27%, respectively; p<0.001). Shah commented that although he and his co-investigators did not have any information on decisions taken prior to surgery, they speculated that there was a “general reluctance” among dementia patients, their carers, and their physicians for the patients to undergo elective procedures. He added that this policy, therefore, may have led to more emergent/urgent procedures. “Similarly, there may be a desire to avoid high-risk procedures in this group of patients,” Shah observed.
Following surgery, according to Shah, “traditional outcomes” were worse with dementia patients. Both 30-day and 90-day mortality were increased in dementia patients compared with patients without dementia: 10% vs. 6% (p<0.001), respectively, and 21% vs. 9%, respectively (<0.001). Hospital length of stay was also significantly longer in dementia patients—8.92 days vs. 5.41 days for patients without dementia (p<0.001). Other differences between dementia and non-dementia patients included dementia patients being less likely to be discharged home, more likely to be discharged to a higher level of care, and having an extended stay in a skilled nursing facility.
Concluding, Shah commented: “Free-for-service Medicare patients with dementia undergoing vascular surgery are older and have more comorbidities, more likely to undergo emergent/urgent procedures, and poorer traditional outcomes.” He added that these results should be used to “help counsel patients/surrogates to achieve goal-concordant care”.
Regarding the ethics of performing vascular surgery in patients who, because of the dementia, may not be able to consent to a procedure and/or who have a poor quality of life, Shah commented that dementia patients were not a “homogenous group” and have varying levels of dementia. Therefore, knowing their goals (e.g. a preference to avoid invasive procedures with prolonged hospital lengths of stay) is “so important before discussing procedures”. “Research is ongoing to see how procedure decisions are made. So, we can avoid certain procedures or do certain procedures that may be less durable but are less physiologically demanding,” he stated.
Speaking to Vascular News, Shah elaborated: “With regard to discussing procedures with persons with dementia, it is essential to first assess whether patients have capacity to make decisions, which often are complex and nuanced in vascular disease. It is often helpful to involve family members or other surrogates even in cases where patient retain capacity. Early involvement of primary care physicians, geriatricians, and palliative care as appropriate is also helpful when appropriate.”