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Dementia is Associated with Early Mortality and Other Adverse Outcomes after Abdominal Aortic Aneurysm Repair
Samir K Shah
1, Lingwei Xiang
2, Gilbert R Upchurch, Jr.
1, Rachel R Adler
2, Khanjan B Shah
1, Clancy J Clark
3, Zara Cooper
4, Emily Finlayson
5, Dae Hyun Kim
6, Joel S Weissman
4 1University of Florida, Gainesville, Gainesville, FL;
2Brigham and Women's Hospital, Boston, MA;
3Virginia Mason, Seattle, WA;
4Brigham and Women's Hospital, Boston, MA;
5University of California, San Francisco, CA, San Francisco, CA;
6Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
Background. Abdominal aortic aneurysm (AAA) repair carries significant risks for mortality and morbidity. These may be higher in patients with Alzheimer's disease and related dementias (ADRD) yet contemporary knowledge of real world outcomes is sparse, complicating high-stakes decision-making. We sought to characterize the outcomes of AAA repair in patients with ADRD.
Methods. We queried Medicare fee-for-service claims (2016-2020) to identify beneficiaries ≥ 66 years who underwent elective, non-ruptured, open or endovascular AAA repair. ADRD was ascertained with a validated 12-month look-back algorithm. We used propensity score-weighted models adjusted for age, sex, race, Elixhauser comorbidity index, frailty, and repair type.
Results. The cohort included 42,733 unique repairs, including 1,817 (4.3%) in patients with ADRD. Compared with the non-ADRD cohort, the ADRD group was older (median 80.8 vs 75.8 years, p<.001), more likely to be female (30.7% vs 25.0%, p<.001) and less likely to be non-Hispanic White (84.2% vs 90.1%, p<.001). Those with ADRD were more likely to receive endovascular repair (89.1% vs 83.8%, p<.001). Unadjusted outcomes were significantly worse (all p<.001) for patients with ADRD, exemplified by 30-day mortality (6.9% vs 3.6%), 90-day mortality (12.7% vs 5.9%), major inpatient complications (23.5% vs 17.9%), 30-day readmission (17.7% vs 11.3%), discharge to higher level care (32.6% vs 11%), and 90-day time-at-home ratio (0.76 vs 0.87). After adjustment, ADRD remained independently associated with worse mortality and readmissions at 30 and 90 days, major inpatient complications, and discharge to higher level of care (
Figure).
Conclusions. In this first-ever national cohort study focused solely on AAA outcomes in patients with dementia, we found that dementia confers clinically meaningful higher risks across a spectrum of outcomes from mortality to discharge to higher levels of care after non-ruptured AAA repair, despite preferential use of minimally invasive repair. These data should be used as a foundation for shared decision-making with patients and surrogate decision makers. Future work should focus on the use of routine cognitive screening, goal-concordant counselling, and peri-operative optimization to improve outcomes and ensure that treatment aligns with patient goals.
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