Cognitive Impairment After Cardiac Surgery: Confounding Factors and Recommendations for Improved Practice

Kathryn M. Bruce; Gregory W. Yelland; Julian A. Smith; Stephen R. Robinson

doi:10.1007/978-981-4560-53-5_4-1

Handbook of Psychocardiology pp 1-45 | Cite as

Cognitive Impairment After Cardiac Surgery: Confounding Factors and Recommendations for Improved Practice

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Authors and affiliations

Kathryn M. Bruce
Gregory W. Yelland
Julian A. SmithEmail author
Stephen R. Robinson

Living reference work entry

First Online: 31 January 2016

Received: 29 September 2014

Accepted: 11 June 2015

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Abstract

Impaired cognition following cardiac surgery is a common complication. Estimates of the incidence of postoperative cognitive decline/dysfunction (POCD) vary from 20 % to 70 % of patients in the week after cardiac surgery to 10–40 % by 6 weeks. It has become evident that differences in research design have contributed significantly to these differing estimates of POCD and that greater consistency will be achieved if future studies utilize appropriate control groups. Recent studies have shown that many patients have cognitive impairment prior to undergoing cardiac surgery and furthermore that some of the POCD is associated with surgical procedures in general, rather than with cardiac surgery in particular. The domains of language, concentration, and motor control are commonly affected during the first week after cardiac surgery, and memory and executive function can also be affected. Some individuals are more vulnerable than others. In the future it might be possible to identify these individuals prior to surgery with computer-based cognitive tests and measures of emotional state, so that the factors involved can be managed and the risk of POCD can be reduced.

Keywords

Cardiopulmonary bypass (CPB) machine Cognitive impairment Post-cardiac surgery (see postoperative cognitive decline/dysfunction (POCD)) Median sternotomy Neuropsychological testing POCD Postoperative cognitive decline/dysfunction (POCD) Anesthesia CABG vs. valve surgery Cardiac surgical factors Cardiopulmonary bypass machine Clinical implications Emotional state effects On cognitive performance Median sternotomy Neuropsychological testing Preoperative cognitive performance Statistical approaches for

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Appendix A

See Table 1.

Table 1

An illustrative sample of studies reviewing the neuropsychological tests used, the methods used to define cognitive impairment and the cognitive impairment found in their studies

Study	Surgery type	Time point 1	Time point 2	Definition of decline	Psychological assessment measures	Core battery used^b	Decline in individual NP tests	Overall prevalence of cognitive impairment (%)
O’Brien et al. (1992)	On-pump CABG valve	10 days	24–40 days	Other^a	Digit span, CPT, CVLT, visual reproduction and logical memory subtests of WMS, PERT	No	Tl: CVLT↓, CPT↓,	Tl: ↓
O’Brien et al. (1992)	On-pump CABG valve	10 days	24–40 days	Other^a		No	T2: CVLT↓	T2: ↔
Vingerhoets et al. (1997)	On-pump CABG valve	7–8 days	6 months	1	RCFT, RAVLT, TMT A and B, Purdue Pegboard, digits test and TAPS test, Stroop color-word test, dot cancellation test, line bisection test, COWAT, token test	Yes	Tl: line bisection↓, RAVLT↓, TAPS test↑; COWAT↑, TMT A↑, token test↑	Tl: 45 %
								T2: 12 %
							T2: CFT↑, TMT A↑, COWAT↑, Stroop Test↑	T2: 12 %
Andrew et al. (1998)	On-pump CABG MIDCAB, 9 SGC, 27 MGC	7 days	Nil	7	CVLT, Purdue Pegboard, COWAT, TMT A and B, digit symbol, Boston naming test, NART, DASS	Yes	MIDCAB: no tests declined over 30 % SGC: Purdue Pegboard 55.6 %; MGC: Purdue Pegboard 44.4 %↓., TMT B 40.7 %↓., digit symbol 40.7 %↓	Tl: decline on four or more measures: 14.3 %↓ MIDCAB; 11.1 %↓ SGC; 44.4 %↓ MGC
Braekken et al. (1998)	On-pump CABG valve	3–5 days	2 months	1	COWAT, CVLT, Grooved Pegboard, TMT A and B, WMS, serial digit learning, letter cancellation test, digit symbol, computerized reaction time test, State-trait anxiety inventory	No	Tl: valve only: Grooved Pegboard↓, letter cancellation test↓, digit symbol↓,	Tl: valve 67 %
								T2: valve 23 %; CABG 14 %
							T2: valve: CVLT↑, state- trait anxiety inventory↑ CABG: CVLT↑, WMS↑, digit symbol↑	T2: valve 23 %; CABG 14 %
Kneebone et al. (1998)	On-pump CABG	7 days	Nil	1,7	CVLT, Purdue Pegboard, COWAT, TMT A and B, digit symbol, Boston naming test	Yes	Tl: RCI method: Purdue Pegboard↓, TMT B↓, digit symbol↓, Boston naming test↓,	Tl: RCI 36 %, SD 0 %
Selnes et al. (1999)	On-pump CABG	1 month	1 year	5	RAVLT, RCFT, symbol digit, Boston naming test, digit span, written alphabet task, Grooved Pegboard, Stroop, NART, MMSE	No	No individual test stats given	Study looking at association between cognitive decrease and medical and intraoperative variables. No overall stats given on performance
Andrew et al. (2000)	On-pump CABG valve combined	6.5 days	Nil	5,7	CVLT, Purdue Pegboard, COPWAT, TMT A and B, digit symbol, Boston naming test, NART	Yes	Digit symbol 28.8 %↓., TMT B 24 %↓.	Tl: 70 %↓. on one or more test, 42 %↓ on two or more tests
Diegeler et al. (2000)	On-pump CABG off-pump CABG	7 days	Nil	4	Syndrom Kurztest (cognition)	No	Tl: Syndrom Kurztest; 90 %↓.on-pump CABG; 0 %↓ off-pump CABG	Tl: 90 %↓.on-pump CABG; 0 %↓. Off-pump CABG
Andrew et al. (2001)	On-pump CABG valve	7 days	6 m	7,2	CVLT, Purdue Pegboard, COWAT, TMT A and B, digit symbol, Boston naming test	Yes	Tl: digit symbol↓. (valve and CABG), TMT B↓ (valve and CABG), CVLT↓ (valve only)	Tl: CABG 50 %, valve 50 %
Andrew et al. (2001)	On-pump CABG valve	7 days	6 m	7,2		Yes	T2: TMT A↓(valve and CABG), TMT B↓ (valve and CABG), digit symbol↓ (valve only)	T2: CABG 27 %, valve 40 %
Baker et al. (2001)	On-pump CABG off-pump CABG	7 days	6 months	7	CVLT, Purdue Pegboard, TMT A and B, digit symbol	Yes	Tests most susceptible to deficits: on-pump CABG-Purdue Pegboard, TMT B, digit symbol. OPCAB-CVLT, digit symbol (not identified as significant deficit)	No difference between groups at Tl or T2
Basile et al. (2001)	On-pump CABG	6 months	Nil	2	MMSE, Randt memory test, judgment of similarities and differences, interpretation of proverbs, nonsense stories, token test, naming of pictures and definitions	No	Tl: MMSE↑; Randt paired words (acquisition and recall)↓	Tl: 37.5 %↓, 62.5 %↑
Di Carlo et al. (2001)	On-pump CABG valve	6 months	Nil	1	MMSE, Randt memory test, token test, confrontation and definitional naming, similarities and differences	No	T2: MMSE↓, Randt memory test↓, token test↓, confrontation naming↓	Tl: 29 %
Ebert et al. (2001)	On-pump CABG valve	2 days	7 days	2	MMSE, COWAT, picture naming, 12 arithmetic tasks, verbal memory, clock reading tasks	No	Tl: CABG and valve: ↓ on all tests except naming but valve had significantly greater decline than CABG on COWART, verbal memory, and arithmetic tasks. T2: CABG: verbal fluency↓, clock reading↓, arithmetic↓. Valve: verbal fluency↓, arithmetic↓, verbal learning↓	Tl: CABG 57 %, valve 71 %
Ebert et al. (2001)	On-pump CABG valve	2 days	7 days	2		No		T2: CABG 19 %, valve 36 %
Grigore et al. (2001)	On-pump CABG	Nil	6 week	1	Randt memory test, digit span, digit symbol, modified visual reproduction test, TMT B	No	T2:Means and SD given only, no significant changes identified in individual tests	T2: 39.3 %↓
Kilo et al. (2001)	On-pump CABG off-pump CABG	7 days	4 months	1	MMSE, TMT A	No	No significant changes on tests	Tl:↔
Kilo et al. (2001)	On-pump CABG off-pump CABG	7 days	4 months	1	MMSE, TMT A	No	No significant changes on tests	T2:↔
Millar et al. (2001)	On-pump CABG	6 days	6 months	1	Stroop test, beck depression inventory	No	Pre-existing cognitive impairment and depression significant factors in decline	Tl: 14 %^b
Millar et al. (2001)	On-pump CABG	6 days	6 months	1	Stroop test, beck depression inventory	No		T2: 2 %^b independent of depression and existing impairment
Newman et al. (2001)	On-pump CABG	7 days	6 weeks, 6 months, 5 year	2	Randt memory test, digit span, Benton revised visual retention, digit symbol substitution, TMT B	No	T2: TMT B↓	Tl: lwk: 53 %
Newman et al. (2001)	On-pump CABG	7 days	6 weeks, 6 months, 5 year	2		No	T2: TMT B↓	T2: 6 weeks, 36 %; 6 months, 24 %; 5 years, 42.5 %
Selnes et al. (2001)	On-pump CABG	1 year	5 year	6	RAVLT, RCFT, symbol digit, Boston naming test, digit span, written alphabet task, Grooved Pegboard, Stroop test, MMSE	No	Tl (ly): ↑RAVLT, ↑RCFT, ↑Stroop, ↑Grooved Pegboard, ↑symbol digit. T2 (5 years): ↓RCFT, ↑Stroop, ↓symbol digit and↓, written alphabet	No percentage impairment given
Silbert et al. (2001)	On-pump CABG	18 h	5 days	2	WMS, TMT A&B, digit span, COWAT	Yes	No individual test scores given	Tl: 30 %
Silbert et al. (2001)	On-pump CABG	18 h	5 days	2	WMS, TMT A&B, digit span, COWAT	Yes	No individual test scores given	T2: 10 %
Abildstrom et al. (2002)	On-pump CABG	5–7 days	3 months	5	ISPOCD test battery: visual verbal learning test, Concept shifting test, Stroop test, letter- digit coding test	No	No individual test stats given. Study looked at comparing patients with and without POCD to cerebral blood flow. No significant difference in cerebral blood flow between groups with POCD and without POCD	Tl: 26.7 %↓
Abildstrom et al. (2002)	On-pump CABG	5–7 days	3 months	5		No		T2: 20 %↓
Ahlgren et al. (2003)	On-pump CABG, PCI	4–6 weeks	Nil	2	TMT A, RCT, RAVLT, computerized driving test: K-test (focused attention), simple reaction time, complex reaction time, simultaneous capacity, reaction time on two choice visual stimuli	No	Decline most frequently seen in TMT A&B, RAVLT, K-test, simple reaction time, and reaction time on two choice visual stimuli, but no numerical stats given to state that they were significantly declined	Tl: CABG 48 %↓, PCI 10 %↓
Rasmussen et al. (2002)	On-pump CABG	7 days	3 months	5	ISPOCD test battery: visual verbal learning test, Concept Shifting Test, Stroop Test, Letter-Digit Coding Test	No	No individual test scores given	Tl: 46.7 %↓
Rasmussen et al. (2002)	On-pump CABG	7 days	3 months	5		No	No individual test scores given	T2: 6.7 %↓
Van Dijk et al. (2002)	On-pump CABG Off-pump CABG	3 m	12 months	5	RAVLT, Grooved Pegboard, TMT A a ndB, Sternberg memory comparison, Line Orientation Test, Stroop Test, CPT, self-ordering tasks, visuospatial working memory test, digit symbol	Yes	No individual test scores given	Tl: on-pump 29.2 % Off-pump 21.1 %
Van Dijk et al. (2002)	On-pump CABG Off-pump CABG	3 m	12 months	5		Yes	No individual test scores given	T2: on-pump 33.6 % Off-pump 30.8 %
Zamvar et al. (2002)	On-pump CABG off-pump CABG	7 days	10 weeks	2	RAVLT, TMT A&B, digit symbol, digit span, Grooved Pegboard, COWART	Yes	Tl: on-pump, Grooved Pegboard↓, digit symbol↓,	Tl: on-pump 66 %, off-pump 27 %
Zamvar et al. (2002)	On-pump CABG off-pump CABG	7 days	10 weeks	2		Yes	T2: on-pump, TMT B↓, Grooved Pegboard↓, digit symbol↓,	T2: on-pump 40 %, off-pump 10 %
Zimpfer et al. (2002)	On-pump CABG valve	7 days	4 months	1	TMT A, MMSE	No	No individual test scores given	Tl: ↔
Zimpfer et al. (2002)	On-pump CABG valve	7 days	4 months	1	TMT A, MMSE	No	No individual test scores given	T2: ↔
Browne et al. (2003)	On-pump CABG	2 days	5 days, 3 months	6	Adult Memory Information Processing Battery	No	No individual test scores given	Tl: 5 days, ↓
Browne et al. (2003)	On-pump CABG	2 days	5 days, 3 months	6	Battery, TMT B, RAVLT, COWAT	No	No individual test scores given	T2: 3 months, ↑ (increased beyond baseline)
Grimm et al. (2003)	Valve	7 days	4 months	1	MMSE, TMT A	No	Replace vs. repair: 7 days and 4 months, ↓TMT A. MMSE ↔ at either time point	No change in valve repair group at 7 days or 4 m. ↓decline in replace group at 7 days and 4 m
Hogue et al. (2003)	On-pump CABG	4–6 weeks	Nil	2	TMT A&B, digit symbol, digit span, Grooved Pegboard, WMS, Benton Visual Form Discrimination, RAVLT	Yes	TMT A&B↓, Benton Visual Form Discrimination↓, Grooved Pegboard↓	Tl: ↔
Lee et al. (2003)	On-pump CABG off-pump CABG	2 weeks	1 year	3	Vocabulary of WAIS, RAVLT, Benton Visual Retention Test, TMT A&B, Grooved Pegboard, finger-tapping test, digit symbol, state anxiety, beck depression	Yes	On-pump: no significant difference on any test at 2 weeks or 1 year. Off-pump: significant ↑ on RAVLT at 2 weeks and 1 year. Both groups ↑improvement on state anxiety at both times	Tl: on-pump 15.4 %↓. vs. off-pump 16.1 %↓
Lee et al. (2003)	On-pump CABG off-pump CABG	2 weeks	1 year	3		Yes		T2: on-pump 14.8 %↓ vs. 18.5 %↓ off-pump
Lund et al. (2003)	On-pump CABG off-pump CABG	3 months	Nil	3	Grooved Pegboard, digit symbol, TMT A&B, digit span, Stroop Test, RAVLT, similarities and vocabulary from WAIS, COWAT, visuoconstructive abilities from WAIS	No	No individual test scores given	Tl: on-pump 35 %↓, off-pump 29 %↓, no significant difference between groups
Rankin et al. (2003)	On-pump CABG off-pump CABG	10 week	Nil	5,6	Boston naming test, COWAT, Rey and Taylor Complex Figure Tests, Judgment of Line Orientation, digit span, TMT A&B, Stroop Test, CVLT, Grooved Pegboard, Ruff Figurai Fluency, MMSE	Yes	CFT↑ (both on- and off-pump)	No significant decline in off- or on-pump CABG
Selnes et al. (2003)	On-pump CABG	3 months	12 months	5	RAVLT, RCFT, Boston naming test, MMSE, TMT A, written alphabet, Grooved Pegboard, TMT B	No	CABG ↑ in verbal memory and global summary measure. Overall ↑ in CABG group on RAVLT, BNT, pegboard compared to nonsurgical controls	Tl: ↔
Selnes et al. (2003)	On-pump CABG	3 months	12 months	5		No		T2: ↔
Stygallet al (2003)	On-pump CABG	6 days	8 weeks, 5 years	6	RAVLT, nonverbal recognition memory task, TMT A&B, block design, finger-tapping test, letter cancellation test, symbol digit replacement test, choice reaction time, displaced reaction time test	No	5 years: RAVLT + TMT A↑, all other tests decline	Most tests decline at 6 days, improve at 8 weeks, then decline at 5 years
Ho et al. (2004)	On-pump CABG	6 months	Nil	2,3,6	Blessed Orientation-Memory-Concentration Test, Behavioral Dyscontrol Scale, TMT A	No	Behavioral Dyscontrol Scale↓, Blessed Orientation-Memory-Concentration Test↓,	Tl: >0.5SD = 4.7 %, >1SD = 8.2 % >20 % = 36.6 %
Kanbaket al. (2004)	On-pump CABG	3 days	6 days	1	MMSE, visual aural digit span		3 days: VADST↓, MMSE ↔ 6 days: VADST return to baseline level, MMSE ↔	No overall percentage change given. Two clinical groups are ofluorane vs. propofol, no difference between groups
Silbert et al. (2004)	On-pump CABG	6 days	Nil	7	CERAD, Symbol Digit Modalities Test, TMT A&B, semantic fluency test, Grooved Pegboard, CogState	Yes	Conventional tests: Grooved Pegboard↓, only significant one. Computerized test: four variable significance ↓ – three types of reaction time, and accuracy	Tl: conventional tests 32 %↓, computerized tests 42 %↓
Askar et al. (2005)	On-pump CABG:	7 days	3 months	3	COGNISTAT (10 subtests assessing orientation, attention, comprehension, repetition, naming, constructions, memory, calculations, similarities, judgment	No	No individual test scores given	Tl: group 1 48.2 %↓; group 2 58.8 %↓
Askar et al. (2005)	On-pump CABG:	7 days	3 months	3		No	No individual test scores given	T2: group 1 37.5 %↓, group 2 29.4 %↓
Carrascal et al. (2005)	On-pump CABG	7 days	Nil	1	PASAT (Paced Auditory Serial Addition Test)	No	Tl: 45.5 %7↓ PASAT	Tl: 45.5 %↓
Kadoi et al. (2005)	On-pump CABG	7 days	6 months	2	MMSE, RAVLT, TMT A&B, digit span, Grooved Pegboard	Yes	TMT A↓, TMT B↓ (7 days), RAVLT↓	Tl: 68 %↓
Kadoi et al. (2005)	On-pump CABG	7 days	6 months	2	MMSE, RAVLT, TMT A&B, digit span, Grooved Pegboard	Yes	TMT A↓, TMT B↓ (7 days), RAVLT↓	T2: 28 %↓
Keizer et al. (2005)	On-pump CABG off-pump CABG	3 m	12 months	2,3,7	RAVLT, Sternberg letter test, TMT A&B, Grooved Pegboard, Stroop Test, Symbol Digit Modalities Test, self-ordering tasks	No	Data on statistically different changes in performance on individual tests was not provided	T1:>SD = 10.5 %, >20 % = 31 %, RCI = 7.7 % T2:RCI = 12.3 %
Kneebone et al. (2005)	On-pump CABG	6 months	Nil	6,8	CVLT, Purdue Pegboard, COWAT, TMT, Boston naming test, digits symbol, NART, DASS	Yes	TMT↓, digit symbol↓	Tl: 43.5 %↓ on 1 test, 18.8 %↓ on 2 tests, 7.1 %↓ on3 tests
Knipp et al. (2005)	Valve	4–7 days	4 months	No definition given	TMT A&B, digit span, Corsi block-tapping test, Horn’s performance test, Zimmerman’s divided attention test, verbal learning test, von Zircon test (mood), general depression scale	No	Discharge:↓TMT A&B, digit span, Corsi block-tapping test. 4 months: ↑digit span, Horn’s performance, depression and mood scales	Tl: discharge: ↓on 5 of 13 tests/subtests
Knipp et al. (2005)	Valve	4–7 days	4 months	No definition given		No		T2: 4 months ↔ from baseline
McKhann et al. (2005)	On-pump CABG off-pump CABG	3 months	12 months	5	RAVLT, RCFT, Boston naming test, digit span, symbol digit, written alphabet, Grooved Pegboard, Stroop Test, MMSE	No	T2: (3 months and 12 months) no significant cognitive decline in any cardiac surgical group	Tl and T2: on-pump CABG ↔; Off-pump CABG ↔
Rothenhausler et al. (2005)	On-pump CABG combined	6–7 days	1 year	2	Syndrom Kurztest (SKT), German version of the ten-item Montgomery-Asberg Depression Rating Scale, PTSS-10 (stress scale)	No	No significant correlation between cognitive dysfunction and MADRS or PTSS-10 scales (i.e., depression or stress levels)	Tl: 38.2 %↓ (17.6 % minimal, 11.8 % mild, 2.9 % severe)
Rothenhausler et al. (2005)	On-pump CABG combined	6–7 days	1 year	2		No		T2: 20 %↓ (13.3 % minimal, 6.7 % moderate)
Selnes et al. (2005)	On-pump CABG	12 months	36 months	5	RAVLT, RCFT, Boston naming test, MMSE, TMT A&B, written alphabet, Grooved Pegboard	No	Boston naming test↓, RAVLT↓, Grooved Pegboard↓	Tl: ↔
Selnes et al. (2005)	On-pump CABG	12 months	36 months	5		No	Boston naming test↓, RAVLT↓, Grooved Pegboard↓	T2: ↔
Stroobant et al. (2005)	On-pump CABG off-pump CABG	6 days	6 months	3	RAVLT, TMT B, Grooved Pegboard, block taps test, line bisection test, COW AT, Judgment of Line Orientation	No	Tl: block taps test↓, line bisection test↓ T2: (on-pump) line bisection test↓ (on- and off-pump) TMT B↓, block taps test↓	Tl: 60 %↓. (59.4 % on-pump CABG, 61.2 % off- pump CABG)
Stroobant et al. (2005)	On-pump CABG off-pump CABG	6 days	6 months	3		No		T2: 24.2 % ↓ (31.8 % on-pump CABG, 9.1 % off-pump CABG)
Boodhwani et al. (2006)	On-pump CABG	6–7 days	Nil	2	Verbal list learning procedure, digit span, Grooved Pegboard, symbol digit, TMT A&B, RAVLT, WMS Memory Scale	Yes	61 %↓ in 1 domain, 30 %↓, in 2 domains, 9 %↓ in 3 domains. No individual test data given	Tl: 59 %↓
Dupuis et al. (2006)	On-pump CABG	5–12 months	Nil	1	Boston naming test, COWAT, digit symbol, Logical Memory Scale, Visual Reproduction Scale, facial recognition test	No	No individual test scores given	No overall percentage change given
Emest et al. (2006)	On-pump CABG off-pump CABG	2 months	6 months	4	RAVLT, Grooved Pegboard, TMT A&B, digit span, digit symbol, letter cancellation test, COWAT, Boston naming test, WMS-R Visual Reproduction, Judgment of Line Orientation, Stroop color-word test	Yes	Tl: no difference between tests and groups in tests	Tl: ↔
Emest et al. (2006)	On-pump CABG off-pump CABG	2 months	6 months	4		Yes	T2: ↑COWAT score in off-pump vs. on-pump at 6 months	T2:↔between on- and off-pump group or baseline
Hammon et al. (2006)	On-pump CABG off-pump CABG	3–5 days	6 weeks, 6 months	3	Not defined: stated in text “Patients underwent an 11-part neuropsychological examination, which was administered by a psychologist. The elements of the test and its results in large numbers of patients in this institution and others have previously been published” referred to Murkin et al. (1995)- statement of consensus	Yes	No individual test scores given	Tl: MC 59.5 %↓; SC 59.5 %↓; OPCAB; 70.2 %↓,
Hammon et al. (2006)	On-pump CABG off-pump CABG	3–5 days	6 weeks, 6 months	3		Yes	No individual test scores given	T2: MC 51 %↓; SC 31.8 %↓; OPCAB 39.2 %↓, T3: MC 57.1 %↓; SC 29.7 %↓; OPCAB 31.7 %↓
Jensen et al. (2006)	On-pump CABG off-pump CABG	3 months	Nil	2,3	MMSE, visual verbal learning test, Concept Shifting Test, Stroop Color-Word Interference Test, Letter-Digit Coding Test	Yes	No individual test scores given	Tl: 1. OPCAB 7.4 %↓, CCAB 9.8 %↓; 2. OPCAB 20.4 %↓, CCAB 23.5 %↓ 3. OPCAB 26.0 %↓ CCAB 21.6 %↓
Lewis et al. (2006)	On-pump CABG	1 week	Nil	2	WLT, TMT A&B, digit symbol, COWAT, Grooved Pegboard	No	T1:CERAD↓, TMT A&B↓, COWAT↓, Grooved Pegboard↓	Tl: two tests = 13.3 %↓; seven tests = 49.4 %↓; adjusted for controls = 8–17.5 %↓
Raymond et al. (2006)	On-pump CABG	2 weeks	Nil	2, 3, 7, 8	MicroCog: assessment of cognitive function	No	Tl: SRB: information processing speed↓, general cognitive functioning↓ all methods: attention/mental control↓	Tl: >1SD = 3.6 %↓, 65.5 %↑ >20 % = 5.5 %↓, 9.1 %t
								RCI = 16.4 %↓,<7 %↑
								SRB = 32.7 %↓, <7 %↑
Rosengart et al. (2006)	On-pump CABG	3 weeks	4 months	1, 4, 7	Digit span, Grooved Pegboard, digit symbol, TMT A&B, Stroop Test, COWAT, visual naming of the Multilingual Aphasia Exam, Hopkins verbal learning test	No	T1:RCI, visual naming of the multilingual aphasia exam↓	Tl:↔
Rosengart et al. (2006)	On-pump CABG	3 weeks	4 months	1, 4, 7		No	T1:RCI, visual naming of the multilingual aphasia exam↓	T2:↔
Szalma et al. (2006)	On-pump CABG	6 weeks	Nil	1	Word fluency test, digit symbol, digit span, block design subtest of WAIS, TMT (Hungarian), RAVLT (Hungarian), Pieron test, Simple Reaction Time, Choice Reaction Time, serial reaction time, Spielberger State-Trait Anxiety Inventory, Beck Depression Inventory	No	No significant changes found on any tests in placebo group	Tl: ↔
Cook et al. (2007)	On-pump CABG, valve combined	7 days	4–6 weeks	3	RAVLT, nonverbal memory test, symbol digit, letter cancellation, TMT A&B, Grooved Pegboard, finger-tapping test	Yes	No individual test scores given	Tl: 88 %↓
Cook et al. (2007)	On-pump CABG, valve combined	7 days	4–6 weeks	3		Yes	No individual test scores given	T2: 30 %↓
Hammon et al. (2007)	On-pump CABG	3–7 days	3–6 weeks, 6 months	3	WAIS, RAVLT, TMT A&B, Grooved Pegboard, finger-tapping test, digit symbol, letter cancellation task, visual reaction time test	No	Data on statistically different changes in performance on individual tests was not provided	T2 (6 months only given): on-pump: 26.0–44.4 %↓, off-pump: 11.5–38.4 %↓
Hernandez et al. (2007)	On-pump CABG off-pump CABG	Day of discharge	6 months	3	Digit span, VIGIL, Grooved Pegboard, RCF, COWAT, Hopkins verbal learning test, WRAT-3, Brixton Spatial Anticipation Test, Beck Depression Inventory, Spielberger State-Trait Anxiety Inventory	No	4 days: TMT A, and state anxiety↓ in OPCAB compared to CABG. 6 months: ↔ in all tests	Tl:↔between groups T2:↔between groups
Ille et al. (2007)	Combined	7 days	Nil	1	Test zur Fruherkennung der Demenz mit Depressionsabgrenzung (TFDD)	No	Only one test used	Tl: 43.2 %↓, 38.6 %↑
Motallebzadeh et al. (2007)	On-pump CABG off-pump CABG	7 days	6 weeks, 6 months	6	MCG complex figure test, Grooved Pegboard, RAVLT, letter cancellation test, Symbol Digit Modalities Test, verbal fluency test	Yes	Data on statistically different changes in performance on individual tests was not provided	Tl: on-pump↓ vs. off-pump
								T2: ↔
								T3: ↔
Nathan et al. (2007)	On-pump CABG	1 week	5 years	6	Buschke Selective Reminding, digit span, TMT A&B, Grooved Pegboard, Symbol Digit Modalities Test	No	Significant changes only identified between groups	Tl: 45 %↓
Nathan et al. (2007)	On-pump CABG	1 week	5 years	6		No	Significant changes only identified between groups	T2: 44 %↓
Puskas et al. (2007)	On-pump CABG	6 weeks	Nil	6	Randt memory test, digit span, digit symbol, TMT B, modified visual reproduction test from WMS	No	No individual test scores given	Tl: diabetic patients, 38 %↓. With hyper, 41 %↓. Without hyper. Nondiabetic: 40 %↓. With hyper, 29 %↓ without hyper
Rubens et al. (2007)	On-pump CABG	5 days	3 months	6	TMT A&B, RAVLT, digit span, COWAT	Yes	Significant changes only identified between groups	Tl: 39 %↓
Rubens et al. (2007)	On-pump CABG	5 days	3 months	6	TMT A&B, RAVLT, digit span, COWAT	Yes	Significant changes only identified between groups	T2: 15.9 %↓
Selnes et al. (2007)	On-pump CABG off-pump CABG	3 months	12 months, 36 months	5	RAVLT, RCF, block design, Boston naming test, Grooved Pegboard, TMT A, written alphabet, MMSE, TMT B	No	36 months: attention domain MMSE, ↑to above baseline levels	T2 (36 months only stats given):↔ relative to baseline across all tests
Tagarakis et al. (2007)	On-pump CABG	1 month	1 year	1	MMSE, Wechsler Memory Scale Revised, Brief Psychiatric Rating Scale, Delirium Rating Scale	No	Tl: all test significant↓	No overall percentage change given
Van Dijk et al (2007)	On-pump CABG off-pump CABG	5 years	Nil	3,7	RAVLT, Grooved Pegboard, TMT A&B, Sternberg memory comparison, Line Orientation Test, Stroop Test, CPT, self-ordering tasks, visuospatial working memory test, Symbol Digit Modalities Test	Yes	Tl: individual test stats do not indicate if significant change occurred within groups	T2: 20 % method, 50.4 %↓ off-pump CABG, 50.4 %↓. On-pump CABG. RCI method: 33.3 %↓ off-pump CABG, 35.0 %↓ on-pump CABG
Yin et al. (2007)	On-pump CABG off-pump CABG	7–10 days	Nil	2	MMSE, digit span, digit symbol, TMT A, Stroop Test, self-rating depression scale, Spielberger State-Trait Anxiety Inventory	Yes	Tl: Off-pump CABG: self-rating depression↓., MMSE ↓, Stroop Test↓.: On- pump CABG: self-rating depression↓, digit span↓, Stroop Test↓	Tl (decline on 2 or more tests): off-pump CABG – 32.5 %↓, on-pump CABG ~52.5 %↓
Mathew et al. (2007)	On-pump CABG	6 weeks	Nil	2	Randt memory test (short story), digit span, modified visual reproduction test, digit symbol, TMT B	No	No individual test scores given	Tl: MH 37.5 %↓, PH 42.5 %↓
Ropacki et al. (2007)	On-pump CABG	1 week	Nil	2	Digit span, digit symbol coding, letter-number sequencing, vocabulary, FAS test, category fluency, Hopkins verbal learning test (HVLT), mental control subtest of WMS, Randt memory test (short story), RCFT, TMT A&B	Yes	Tl: 47.6 %↓ on psychomotor speed (TMT A and digit symbol), 45.2 %↓. On working memory and executive function (FAS test, digit span, TMT B, letter-number sequencing), 57.1 %↓. Verbal memory (short story of Randt memory test, HVLT), 16.7 %↓ visual memory (RCFT)	Tl: 66.7 %↓
Cicekcioglu et al. (2008)	Off-pump CABG valve	6 days	2 months	1	Raven’s standard progressive matrices (RSPM), RAVLT, Stroop Test, Line Orientation Test (LOT)	Yes	Tl: RSPM↔, LOT↓., RAVLT↑, Stroop↑	No overall percentage decline stated
Cicekcioglu et al. (2008)	Off-pump CABG valve	6 days	2 months	1		Yes	T2: RSPM↔, LOT↔, RAVLT↑, Stroop↑	No overall percentage decline stated
Hong et al. (2008)	Valve	7 days	Nil	1	MMSE, TMT A, Grooved Pegboard	No	Tl: MMSE ↔, TMT A↓, Grooved Pegboard↓	Tl: 23 %↓
Sweet et al. (2008)	On-pump CABG PCI	3 weeks	4 months, 12 months	5,7	Digit span; GP; digit symbol; TMT A; Stroop color-word test; COWAT; visual naming of the multilingual aphasia examination (MAE); TMT B; HVLT-R	Yes	No clear pattern of change found	Tl: ↔
								T2: ↔
								T3: ↔
Slater et al. (2009)	On-pump CABG	1 week	3 months	2	MMSE; TMT A; TMT B; HVLT; GP; Stroop color and word test; saccadic/antisaccadic eye movement; hospital anxiety and depression scale (HADS)	Yes	No individual test scores given	Tl: 60 %↓
Slater et al. (2009)	On-pump CABG	1 week	3 months	2		Yes	No individual test scores given	T2: 29 %↓
Kozora et al. (2010)	On-pump CABG off-pump CABG	12 months	Nil	2	Logical memory and faces subtest from Wechsler Memory Scale; digit span; digit symbol; TMT A; TMT B; clock drawing; BDI	No	No individual test scores given	Tl: 12 % in-pump and 13.2 % off-pump decline; 37.9 % on-pump and 41.6 % off-pump improve
Anastasiadis et al. (2011)	On-pump CABG	1 week	3 months	3	Judgment of Line Orientation Test; Stroop color-word test; Symbol Digit Modalities Test; digit span – forward; digit span –backward; Fuld Object Memory Evaluation; Positive and Negative Affect Schedule; Spielberger State-Trait Anxiety Inventory; Geriatric Depression Scale	Yes	No significant changes reported (reported as % change instead)	Tl: 53 %↓
Anastasiadis et al. (2011)	On-pump CABG	1 week	3 months	3		Yes		T2: 41 %↓
Maekawa et al. (2011)	On-pump CABG off-pump CABG valve combined	1 week	Nil	3	Hasegawa dementia scale; digit span; digit symbol; Kana Pick-out Test	No	No individual test scores given	Tl: off-pump CABG 18 %↓; on-pump CABG 23 %↓; CABG/Valve 11 %↓; valve 48 %↓
Hudetz et al. (2011)	On-pump CABG valve	1 week	Nil	5	Memory and work list memory from Repeatable Battery for the Assessment of Neuropsychological status, brief visual memory test revised, backward digit span, semantic memory, phonemic memory, geriatric depression scale	No	No individual test scores given	Tl: 50 %↓
Hudetz et al. (2011)	combined	1 week	Nil	5		No	No individual test scores given	Tl: 50 %↓
Djaiani et al. (2012)	On-pump CABG	12 months	Nil	5	RAVLT; Rey visual design learning test; TMT A&B; GP; forward digit span; backward digit span; spatial span forward; spatial span backward; choice and simple reaction time tests; verbal fluency test	No	Significant decline on; Rey visual design learning test↓; GP↓; verbal fluency test↓	Tl: 17.4 %↓
Meybohm et al. (2013)	On-pump CABG valve combined	5–7 days	Nil	1,5	Core battery of ten tests including the following four main domains: memory, motor skills, attention, and executive function (no test names given)	Yes	Summary statistics given for SD method and no individual test differences were shown using z-score measure	Tl: SD method, 52 %↓ and 23 %↑; z-score ↔
Meybohm et al. (2013)	On-pump CABG valve combined	5–7 days	Nil	1,5		Yes		T2: SD method, 21 %↓ and 36 %↑; z-score ↔

^aDefinitions of decline: see section “Statistical Approaches for Defining Postoperative Cognitive Change”

^bCore battery-based consensus statement from Murkin et al. (1995) paper

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Kathryn M. Bruce
- 1
Gregory W. Yelland
- 2
Julian A. Smith
- 1
Email author
Stephen R. Robinson
- 2

1.Department of SurgeryMonash University, Monash Medical CentreClaytonAustralia
2.School of Health SciencesRMIT UniversityBundooraAustralia

Cognitive Impairment After Cardiac Surgery: Confounding Factors and Recommendations for Improved Practice

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