Sleep disturbances, cognitive reserve, and continuing pain and inflammation are other
risk factors contributing to delirium (confusion and agitation) and neurocognitive
decline (in the long term) following heart surgery. Investigators aim to test a bundle of
sleep optimization, cognitive exercise before surgery, and extended pain relief for 48
hours with intravenous acetaminophen combined with enhanced recovery after surgery
protocols (SCOPE bundle). SCOPE will fill significant gaps in evidence by testing the
value of a patient and care-provider-focused intervention that can potentially minimize
POD and improve outcomes (cognitive & physical function, sleep quality, pain, depression
or anxiety, and survival) important to patients and families.
The SCOPE trial will address many heart surgery outcome-related questions commonly asked
by patients:
What can I do to reduce my chances of developing confusion, hallucinations, or delirium
after surgery? How can I best prepare before surgery to improve my long-term health and
avoid disability? Are there exercises I can participate in that improve my sleep, pain,
and mood after surgery? Intellectual pursuits, physical activity, and social interactions
support cognitive reserve, while poor health, poor sleep hygiene, poor nutrition, and
mental health disease can diminish reserve. Various interventions with different
intensities and timing to augment cognitive reserve have been associated with positive
outcomes on neuropsychological testing. Adaptive video gaming for as little as 10 hours
leads to the maintenance of independence in activities of daily living and sustained
improvements in speed of processing, attention, and working memory in older people.
Likely through the increased cognitive reserve, perioperative brain exercise aims to
protect against morbid cognitive recovery after surgery.
Sleep is vital for memory and cognitive function. Poor sleep traits in older adults that
are potentially modifiable, including short/long duration, daytime napping, and
associated sleepiness, led to an almost 2-fold increase in delirium risk. Patients will
complete an evidence-based course on healthy sleep habits and will complete guided
exercises designed to restructure behaviors and thinking. They are encouraged to follow a
set of recommendations to improve their sleep (e.g., optimal sleep duration, advice for
habits such as daytime napping, maintaining a regular sleep schedule, avoiding caffeine,
regular daylight exposure, dimming lights or electronics and relaxation and thought
exercises for optimal sleep); many of these sleep behaviors have been strongly linked to
increased risk for cognitive decline. Investigators propose that sleep optimization
before AND after (an established best practice sleep bundle) surgical insult will
contribute to cognitive reserve leading to decreased delirium risk and key
patient-centered outcomes (postoperative sleep, pain, cognition, mood, and survival).
Inadequate pain relief and opioids are both risk factors for delirium. Surgery on the
chest is a significant pain source. Approximately 30-75% of patients suffer from moderate
to severe pain in the postoperative period. Almost half of the patients have severe pain
at rest, and three-quarters have severe pain during coughing and movement. Pain and
inflammation are closely biochemically linked.
Sleep, brain exercise, and adequate pain control with opioid-sparing can be additive or
synergistic interventions to prevent delirium following heart surgery.
Investigators propose three specific aims by conducting a 1:1 randomized controlled trial
in 406 heart surgery patients 60 or older undergoing heart surgery. They will be
administered perioperative sleep optimization, brain exercise training, and intravenous
acetaminophen over 48 hours. A trained expert will administer the sleep and cognitive
exercise protocols at least two weeks before surgery. This expert will handhold the
patients for two weeks until the surgery. Thus, the gains made before surgery with better
sleep quality and improved brain reserve will be sustained with postoperative pain
control to lower the ongoing inflammation. Through this trial, investigators will
evaluate if the SCOPE bundle can reduce 1) in-hospital delirium, 2) long-term (one, six,
and twelve months) cognitive, physical, and self-care function, and 3) barriers to
implementation of this bundle.
Currently, no options are routinely available to patients to optimize their sleep and
cognition before cardiac surgery. The proposed research is significant because it will be
the first to test the bundled behavioral intervention approach (sleep optimization, brain
exercise) before surgery with extended, scheduled pain management with non-opioids
following surgery. The SCOPE trial will yield relevant and immediately actionable data to
improve care for over 900,000 adults in the U.S. each year.
