Cognitive and Physical Optimization in Prevention of Postoperative Cognitive Deficit in Elderly With Lung Resection

Incidence of newly diagnosed or worsening of the existing postoperative cognitive decline assessed by change in score of MMSE - Mini-Mental State Examination (an 11-question measure that tests five areas of cognitive function: orientation, registration, attention, and calculation, recall, and language). On a scale from 0-30 points:

≥ 25 points normal cognitive function 19-24 points minor cognitive dysfunction 10-18 points medium cognitive dysfunction

≤ 9 points major cognitive dysfunction In this study change of 3 or more points in MMSE between two tests ( pre and postoperative) or between individual participants will be marked as significant

Perioperative assessment of depression, anxiety, and stress: DAS - depression and anxiety assessment scale (42-item self-report scale measures the negative emotional states of depression, anxiety, and stress)

Scoring Guide DASS (42) Scoring Depression Anxiety Stress Normal 0-9 0-7 0-14 Mild 10-13 8-9 15-18 Moderate 14-20 10-14 19-25 Severe 21-27 15-19 26-33 Extremely Severe 28+ 20+ 34+

Results are assessed between the intervention group and control

Incidence of newly diagnosed postoperative delirium: CAM-ICU (Confusion Assessment Method for the ICU) using CAM-ICU Flowsheet:

Step 1. Acute Change or Fluctuating Course of Mental Status: yes (delirium positive) or no (CAM-ICU negative) Step 2. Inattention: 0 - 2 errors (CAM-ICU negative) or > 2 errors go to next step Step 3. Altered Level of Consciousness (the Richmond Agitation-Sedation Scale - RASS): from -5 (unarousable - no response to voice or physical stimulation) to +4 (combative). Anything other than 0 (alert and calm) goes to the next step.

Step 4. Disorganized thinking: 0-1 errors (not delirious) or > 1 error (delirious) Feature 1 plus 2 and either 3 or 4 present = CAM-ICU positive

Assessment of the functional status and speed of recovery - Clinical frailty scale: from 1 (very fit) to 9 (terminally Ill). Only patients marked as less than 6 are included in the study.

Any change in the assessment score is marked as significant

Assessment of the functional status and speed of recovery - the New mobility score is a composite score of the patient's ability to perform:

• indoor walking,
• outdoor walking
• shopping

providing a score between zero and three (0: not at all, 1: with help from another person, 2: with an aid, 3: no difficulty) for each function. The total score can be from 0 to 9, with 9 indicating a high functional level.

Assessment of the speed of recovery - A test of functional recovery: 10 items for assessing basic activities by a six-level ordinal scale 0 (activity not achieved) -5 (fully independent and secure). Total scores can range from 0 to 50 (from inability to perform any activity to complete independence.) Speed of recovery will be assessed with a comparison of the scores during the first 5 postoperative days.

Assessment of the functional status and speed of recovery Timed up and go test is performed by measuring the time for the following sequence of actions:

• Stand up from the chair.
• Walk to the line on the floor at a normal pace.
• Turn.
• Walk back to the chair at a normal pace.
• Sit down again.

Mobility is assessed based on time to complete the test:

< 10 seconds = normal < 20 seconds = good mobility; can walk outside alone; does not require a walking aid < 30 seconds = walking and balance problems; cannot walk outside alone; requires walking aid

Complication rate will be presented as % of patients within the groups who develop:

• Respiratory failure
• Pneumonia
• Atelectasis
• Bronchospasm
• Bronchopleural fistula
• Air leak
• Pulmonary edema

Morbidity will be presented as % of patients within the groups who develop any kind of complication or illness postoperatively during the period of follow-up

Mortality will be presented as overall and % of deaths in the study population and both groups