Abstract
Background
Cognitive impairment or dementia has been linked to adverse outcomes in orthopedic surgery. However, studies evaluating its impact on perioperative outcomes after total shoulder arthroplasty (TSA) have been limited. The aim of this study is to examine the association between pre-operative dementia and short-term outcomes following TSA.
Methods
Patients undergoing elective primary TSA over 2021-2023 were retrospectively identified and analyzed in the National Surgical Quality Improvement Program database. Patients with and without dementia were matched based on patient demographics and comorbidities. Thirty-day post-operative outcomes such as length of stay and complications were analyzed via univariate analyses.
Results
A total of 6,120 patients who underwent elective primary TSA were identified. After 5:1 propensity matching, 219 patients with pre-operative dementia and 1,095 patients without pre-operative dementia were included. The dementia cohort, on average, experienced a longer length of stay (2.2 ± 3.0 days vs. 1.7 ± 4.3 days, P = .047), more frequent discharge to a nonhome setting (26.5% vs. 13.3%, P < .001), and a higher rate of readmission within 30 days (8.7% vs. 4.7%, P = .029). In addition, this cohort had higher rates of overall complications (10.0% vs. 6.0%, P = .043) and minor complications (7.8% vs. 3.9%, P = .021), as well as the rate of bleeding resulting in transfusion (5.5% vs. 2.0%, P = .007).
Conclusions
Pre-operative dementia is associated with significant increases in adverse short-term outcomes in TSA patients. Dementia may limit patients' ability to follow post-operative instructions, participate in rehabilitation, and manage comorbidities, contributing to worse outcomes. These findings underscore the need for healthcare teams to optimize perioperative and post-operative care in patients with dementia.
Keywords: Cognitive impairment, Dementia, Cognitive dysfunction, Total shoulder arthroplasty, Discharge destination, Post-operative complications
Introduction
Total shoulder arthroplasty (TSA) cases have increased greatly in recent years in the United States, growing at a faster rate compared to total knee and hip arthroplasties.34 By successfully restoring shoulder joint function, this procedure serves as a viable option for patients facing degenerative or inflammatory shoulder conditions. TSA incidence continues to increase throughout the decade, with the number of TSA cases projected to reach 400,000 by 2030.5,24 Therefore, it is important to identify relevant risk factors when assessing short-term outcomes and potential complications of TSA.
Dementia or cognitive impairment presents with a decline in cognitive function that frequently develops in the age range of patients undergoing total joint arthroplasties such as TSA.10,12 Previous studies have shown how dementia leads to adverse outcomes in orthopedic surgery, including elevated rates of post-operative complications in total hip arthroplasty (THA).16 Another study reported that patients with pre-existing cognitive impairment experienced poorer post-operative recovery after total knee arthroplasty (TKA), with higher rates of delirium, reduced functional independence, and a greater likelihood of discharge to rehabilitation or assisted nursing facilities.19 Nevertheless, the broader impact of dementia on post-operative outcomes in TSA remains understudied. Existing research is limited, with one study reporting increased surgical complications over a 2-year follow-up in patients with pre-operative dementia and another identifying increased risk of perioperative outcomes in patients with pre-operative psychiatric illnesses who underwent shoulder arthroplasty from 1990 to 2007.4,33
Given the projected rise in TSA utilization and the growing prevalence of cognitive impairment in the population, this study aimed to determine the effect of pre-operative dementia on short-term outcomes for patients who have undergone TSA. The authors hypothesized that patients with dementia would be at increased risk for adverse outcomes post-operatively following TSA. Understanding the link between cognitive impairment and TSA may inform clinical decision-making and guide perioperative care of these patients.
Methods
Because this was a retrospective analysis of a publicly available, deidentified national database, it did not require institutional review board approval.
Patient selection
The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database collects patient demographics, surgical case profiles, and 30-day post-operative outcomes from over 700 hospitals in the United States and Canada. Using the Current Procedural Terminology code 23472, patients who underwent primary reverse and anatomic TSA between 2021 and 2023 were identified.
Baseline demographics and comorbidities included age, sex, height, weight, smoking status, diabetes mellitus, American Society of Anesthesiologists (ASA) classification, pre-operative functional status, hypertension requiring medication, history of severe chronic obstructive pulmonary disease, ascites, heart failure within 30 days before surgery, disseminated cancer, dialysis use, ventilator use, bleeding disorder, and pre-operative packed red blood cell transfusion <72 hours before surgery. Body mass index (BMI) was calculated using the following equation: BMI = (weight in pounds)/(height in inches)2 × 703.
Exclusion criteria included patients who had missing baseline characteristics (N = 13,687), who did not have a documented discharge (N = 1), who passed away during hospitalization (N = 4), who left against medical advice (N = 2), or whose surgeries were emergent or urgent cases (N = 167). Using the “HXDEMENTIA” variable, patients were divided into 2 groups: those with a history of dementia or cognitive impairment, and those without a history of dementia or cognitive impairment.
Thirty-day post-operative outcomes of interest were evaluated. The following complications were classified as minor: superficial surgical site infection, urinary tract infection, deep venous thrombosis, and bleeding requiring transfusion. The following complications were defined as major: ventilator use for more than 48 hours, unplanned intubation, pneumonia, myocardial infarction, stroke, progressive renal insufficiency or acute renal failure requiring dialysis, pulmonary embolism, deep surgical site infection, wound dehiscence, sepsis, or septic shock.
Statistical analyses
Before matching, demographics and comorbidities were compared between patients with and without dementia or cognitive impairment using univariate analyses (2-sided independent-samples t-tests, chi-square tests, or Fisher's exact tests). A 5:1 nearest-neighbor propensity score matching without replacement was then performed, controlling for baseline demographics and comorbidities. Significant differences in demographics, comorbidities, and 30-day post-operative outcomes between the matched cohorts were identified via 2-sided independent-samples t-test, chi-square test, and Fisher's exact test when appropriate.
As a sensitivity analysis, multivariable regression analyses in the full eligible cohort (N = 6,120) assessed the independent association between pre-operative dementia or cognitive impairment and 30-day outcomes. Logistic regression was used for binary outcomes, and linear regression was used for length of stay. Models adjusted for age, sex, BMI, smoking status, diabetes, ASA class ≥3, functional status, hypertension requiring medication, chronic obstructive pulmonary disease, ascites, congestive heart failure, disseminated cancer, dialysis use, ventilator dependence, bleeding disorder, and pre-operative transfusion within 72 hours.
All analyses were performed using R programming (RStudio version 4.4.0, Boston, MA), with statistical significance set at P < .05.
Results
Patient demographics and comorbidities
After exclusion, a total of 6,120 patients who underwent elective primary TSA were included, of which 219 (3.6%) had pre-operative cognitive impairment/dementia. Baseline characteristics are shown in Table I. Prior to matching, patients with cognitive impairment were more likely to be older (81.01 ± 4.33 vs. 79.35 ± 3.68, P < .001, Table I) and have a lower BMI (28.04 ± 5.35 vs. 29.55 ± 5.84, P < .001, Table I). Such patients also had increased rates of nonindependent functional status (20.1% vs. 3.7%, P < .001, Table I), ASA classification ≥3 (79.0% vs. 66.4%, P < .001, Table I), heart failure within 30 days before surgery (12.8% vs. 5.7%, P < .001, Table I), and pre-operative packed red blood cell transfusion within 72 hours before surgery (1.4% vs. 0.2%, P = .010, Table I).
Table I.
Baseline characteristics of patients undergoing elective primary total shoulder arthroplasty before propensity score matching, stratified by pre-operative cognitive impairment.
| Variables | Total sample n = 6,120 |
No cognitive impairment n = 5,901 |
Cognitive impairment n = 219 |
P value∗ |
|---|---|---|---|---|
| Age (yr) | 79.41 ± 3.72 | 79.35 ± 3.68 | 81.01 ± 4.33 | <.001 |
| Sex | .956† | |||
| Female | 3,809 (62.2) | 3,671 (62.2) | 138 (63.0) | |
| Male | 2,285 (37.3) | 2,204 (37.3) | 81 (37.0) | |
| Nonbinary | 26 (0.4) | 26 (0.4) | 0 (0.0) | |
| BMI | 29.50 ± 5.83 | 29.55 ± 5.84 | 28.04 ± 5.35 | <.001 |
| Nonindependent functional status | 260 (4.2) | 216 (3.7) | 44 (20.1) | <.001 |
| ASA classification ≥ 3 | 4,092 (66.9) | 3,919 (66.4) | 173 (79.0) | <.001 |
| Smoker | 184 (3.0) | 177 (3.0) | 7 (3.2) | 1.000 |
| Diabetes mellitus | 1,107 (18.1) | 1,056 (17.9) | 51 (23.3) | .052 |
| Hypertension requiring medication | 4,584 (74.9) | 4,417 (74.9) | 167 (76.3) | .696 |
| History of severe COPD | 419 (6.8) | 399 (6.8) | 20 (9.1) | .219 |
| Ascites (liver disease) | 0 (0.0) | 0 (0.0) | 0 (0.0) | N/A |
| Heart failure within 30 d before surgery | 362 (5.9) | 334 (5.7) | 28 (12.8) | <.001 |
| Disseminated cancer | 10 (0.2) | 10 (0.2) | 0 (0.0) | 1† |
| Currently on dialysis (renal failure) | 12 (0.2) | 10 (0.2) | 2 (0.9) | .066† |
| Ventilator use | 1 (0.0) | 1 (0.0) | 0 (0.0) | 1† |
| Bleeding disorder | 188 (3.1) | 176 (3.0) | 12 (5.5) | .057† |
| Preoperative pRBC transfusion < 72 h before surgery | 13 (0.2) | 10 (0.2) | 3 (1.4) | .010† |
ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; pRBC, packed red blood cells.
Values expressed as mean ± standard deviation or n (%).
Significant values in bold.
Indicates Fisher's exact test used.
5:1 propensity score matching matched 1,095 patients without cognitive impairment to 219 patients with cognitive impairment. After matching, the 2 cohorts no longer differed significantly in any baseline characteristic (Table II).
Table II.
Baseline characteristics of patients undergoing elective primary total shoulder arthroplasty after propensity score matching, stratified by pre-operative cognitive impairment.
| Variables | Total sample n = 1,314 |
No cognitive impairment n = 1,095 |
Cognitive impairment n = 219 |
P value∗ |
|---|---|---|---|---|
| Age (yr) | 81.00 ± 4.31 | 81.00 ± 4.30 | 81.01 ± 4.33 | .957 |
| Sex | .799 | |||
| Female | 815 (62.0) | 677 (61.8) | 138 (63.0) | |
| Male | 499 (38.0) | 418 (38.2) | 81 (37.0) | |
| BMI | 27.91 ± 5.30 | 27.88 ± 5.29 | 28.04 ± 5.35 | .699 |
| Nonindependent functional status | 230 (17.5) | 186 (17.0) | 44 (20.1) | .314 |
| ASA classification ≥ 3 | 1,034 (78.7) | 861 (78.6) | 173 (79.0) | .976 |
| Smoker | 40 (3.0) | 33 (3.0) | 7 (3.2) | 1 |
| Diabetes mellitus | 323 (24.6) | 272 (24.8) | 51 (23.3) | .688 |
| Hypertension requiring medication | 1,000 (76.1) | 833 (76.1) | 167 (76.3) | 1 |
| History of severe COPD | 112 (8.5) | 92 (8.4) | 20 (9.1) | .825 |
| Ascites (liver disease) | 0 (0.0) | 0 (0.0) | 0 (0.0) | N/A |
| Heart failure within 30 d before surgery | 164 (12.5) | 136 (12.4) | 28 (12.8) | .970 |
| Disseminated cancer | 0 (0.0) | 0 (0.0) | 0 (0.0) | N/A |
| Currently on dialysis (renal failure) | 9 (0.7) | 7 (0.6) | 2 (0.9) | .651† |
| Ventilator use | 0 (0.0) | 0 (0.0) | 0 (0.0) | N/A |
| Bleeding disorder | 74 (5.6) | 62 (5.7) | 12 (5.5) | 1† |
| Preoperative pRBC transfusion < 72 h before surgery | 13 (1.0) | 10 (0.9) | 3 (1.4) | .464† |
ASA, American Society of Anesthesiologists; BMI, body mass index; COPD, chronic obstructive pulmonary disease; pRBC, packed red blood cells.
Values expressed as mean ± standard deviation or n (%).
Significant values in bold.
Indicates Fisher's exact test used.
Complication rates
Thirty-day post-operative complications after TSA are shown in Table III. On average, patients with cognitive impairment had a statistically significant increased length of stay (2.2 ± 3.0 days vs. 1.7 ± 4.3 days, P = .047, Table III). They were also more likely to be discharged to a nonhome setting (26.5% vs. 13.3%, P < .001, Table III) and be readmitted within 30 days (8.7% vs. 4.7%, P = .029, Table III). Patients with cognitive impairment had increased rates of overall complications (10.0% vs. 6.0%, P = .043, Table III) and minor complications (7.8% vs. 3.9%, P = .021, Table III), which was driven largely by a higher rate of bleeding resulting in transfusion (5.5% vs. 2.0%, P = .007, Table III).
Table III.
Univariate analysis of post-operative outcomes of patients undergoing elective primary total shoulder arthroplasty after propensity score matching, stratified by pre-operative cognitive impairment.
| Variables | Total sample n = 1,314 |
No cognitive impairment n = 1,095 |
Cognitive impairment n = 219 |
P value∗ |
|---|---|---|---|---|
| Length of total hospital stay (d) | 1.8 ± 4.1 | 1.7 ± 4.3 | 2.2 ± 3.0 | .047 |
| Nonhome discharge | 204 (15.5) | 146 (13.3) | 58 (26.5) | <.001 |
| Readmission | 71 (5.4) | 52 (4.7) | 19 (8.7) | .029 |
| Mortality | 2 (0.2) | 2 (0.2) | 0 (0.0) | 1† |
| Any complication | 88 (6.7) | 66 (6.0) | 22 (10.0) | .043 |
| Any minor complication | 60 (4.6) | 43 (3.9) | 17 (7.8) | .021 |
| Superficial surgical site infection | 4 (0.3) | 3 (0.3) | 1 (0.5) | .518† |
| Urinary tract infection | 13 (1.0) | 11 (1.0) | 2 (0.9) | 1† |
| Vein thrombosis requiring therapy | 11 (0.8) | 8 (0.7) | 3 (1.4) | .406† |
| Bleeding resulting in transfusion | 34 (2.6) | 22 (2.0) | 12 (5.5) | .007 |
| Any major complication | 36 (2.7) | 30 (2.7) | 6 (2.7) | 1 |
| Ventilator use > 48 h | 2 (0.2) | 1 (0.1) | 1 (0.5) | .306† |
| Unplanned intubation | 4 (0.3) | 3 (0.3) | 1 (0.5) | .518† |
| Pneumonia | 8 (0.6) | 7 (0.6) | 1 (0.5) | 1† |
| Myocardial infarction | 4 (0.3) | 4 (0.4) | 0 (0.0) | 1† |
| Stroke | 7 (0.5) | 5 (0.5) | 2 (0.9) | .330† |
| Progressive renal insufficiency/acute renal failure requiring dialysis | 0 (0.0) | 0 (0.0) | 0 (0.0) | N/A |
| Pulmonary embolism | 8 (0.6) | 6 (0.5) | 2 (0.9) | .627† |
| Deep surgical site infection | 3 (0.2) | 3 (0.3) | 0 (0.0) | 1† |
| Wound dehiscence | 3 (0.2) | 3 (0.3) | 0 (0.0) | 1† |
| Sepsis or septic shock | 5 (0.4) | 4 (0.4) | 1 (0.5) | 1† |
Values expressed as mean ± standard deviation or n (%).
Significant values in bold.
Indicates Fisher's exact test used.
Sensitivity analysis
In multivariable analyses of the full eligible cohort (Table IV), pre-operative dementia or cognitive impairment remained independently associated with longer length of stay (β = 0.51 days; 95% confidence intervals (CI): [0.14–0.88], P = .007), increased nonhome discharge (odds ratio (OR) = 2.90; 95% CI: [2.03–4.10], P < .001), and higher 30-day readmission (OR = 1.90; 95% CI: [1.10–3.13], P = .015).pre-operative dementia or cognitive impairment remained independently associated with longer length of stay (β = 0.51 days; 95% confidence intervals (CI): [0.14–0.88], P = .007), increased nonhome discharge (odds ratio (OR) = 2.90; 95% CI: [2.03–4.10], P < .001), and higher 30-day readmission (OR = 1.90; 95% CI: [1.10–3.13], P = .015). Dementia or cognitive impairment was also associated with increased odds of any complication (OR = 1.93; 95% CI: [1.16–3.08], P = .008) and any minor complication (OR = 2.05; 95% CI: [1.14–3.47], P = .011), including bleeding requiring transfusion (OR = 2.62; 95% CI: [1.25–5.04], P = .006).
Table IV.
Multivariate analysis of post-operative outcomes of patients undergoing elective primary total shoulder arthroplasty in the entire eligible cohort (N = 6,120), stratified by pre-operative cognitive impairment.
| Variables | Odds ratio/coefficient | 95% CI | P value∗ |
|---|---|---|---|
| Length of total hospital stay (d) | β = 0.51 | (0.14, 0.88) | .007 |
| Nonhome discharge | OR = 2.90 | (2.03, 4.10) | <.001 |
| Readmission | OR = 1.90 | (1.10, 3.13) | .015 |
| Mortality | N/A | N/A | N/A |
| Any complication | OR = 1.93 | (1.16, 3.08) | .008 |
| Any minor complication | OR = 2.05 | (1.14, 3.47) | .011 |
| Superficial surgical site infection | OR = 2.35 | (0.13, 12.75) | .423 |
| Urinary tract infection | OR = 0.77 | (0.12, 2.65) | .733 |
| Vein thrombosis requiring therapy | OR = 2.43 | (0.54, 7.71) | .178 |
| Bleeding resulting in transfusion | OR = 2.62 | (1.25, 5.04) | .006 |
| Any major complication | OR = 1.43 | (0.54, 3.18) | .421 |
| Ventilator use > 48 h | OR = 8.73 | (0.24, 163.18) | .171 |
| Unplanned intubation | OR = 3.05 | (0.15, 20.50) | .334 |
| Pneumonia | OR = 0.95 | (0.05, 4.81) | .962 |
| Myocardial infarction | N/A | N/A | N/A |
| Stroke | OR = 3.88 | (0.53, 17.80) | .115 |
| Progressive renal insufficiency/acute renal failure requiring dialysis | N/A | N/A | N/A |
| Pulmonary embolism | OR = 2.31 | (0.34, 8.85) | .288 |
| Deep surgical site infection | N/A | N/A | N/A |
| Wound dehiscence | N/A | N/A | N/A |
| Sepsis or septic shock | OR = 1.88 | (0.10, 11.51) | .570 |
CI, confidence interval; OR, odds ratio
For outcomes with zero events in one group, model estimates were not estimable and are reported as N/A.
Significant values in bold.
Discussion
In the present study, patients with dementia or cognitive impairment were found to have worse short-term outcomes than propensity-matched controls without dementia or cognitive impairment. Specifically, the dementia cohort experienced a longer length of stay, was more frequently discharged to a nonhome setting, and had higher 30-day readmission rates. They also had higher 30-day overall and minor complication rates, driven largely by increased bleeding requiring transfusion.
Few studies have investigated the association between dementia or cognitive impairment and post-operative outcomes after elective TSA. Existing conclusions are largely extrapolated from broader populations of orthopedic and general surgery patients and may include procedures for emergent and urgent indications. For instance, Hu et al investigated dementia patients undergoing a variety of surgeries including not only musculoskeletal but also neurosurgical, gastrointestinal, urologic, and cardiovascular procedures and found significantly higher post-operative complication rates, medical resource use, and in-hospital expenditures compared to controls.15
Even within orthopedic surgery, most of the data regarding cognitive impairment come from lower extremity procedures such as THA and TKA.9,11,16,19 For instance, Krishnan et al found that patients with cognitive impairment undergoing TKA had higher rates of post-operative complications, worsened post-operative functional status, and a higher likelihood of nonhome discharge.19 Johnson et al similarly studied complications up to 5 years following THA and TKA and found patients with dementia were more likely to be readmitted and that patients undergoing THA with dementia had worse outcomes than both those undergoing THA without dementia and those undergoing TKA with dementia.16 Similarly, while a systematic review by Chen et al on patients with cognitive impairment undergoing a variety of noncardiac surgeries included 4 studies on orthopedic patients, these were limited to outcomes following THA, TKA, and spinal procedures.7
Even with the majority of TSA procedures being performed electively, the overall rate of elective TSA continues to grow due to increases in life expectancy, expansion of indications for TSA, and improvements in implant technology. Given the prevalence of cognitive impairment among patients undergoing TSA, a few studies have examined the association between psychiatric and neurologic disorders and shoulder arthroplasty. Bot et al evaluated conditions such as depression, anxiety, schizophrenia, and dementia in relation to perioperative outcomes following partial or total shoulder arthroplasty.4 Wong et al also investigated the impact of mental health conditions, though dementia was not included in their analysis.38 Serna et al specifically examined dementia in the context of shoulder arthroplasty using the PearlDiver database.29 However, their study did not delineate the timing of complications within the 2-year follow-up period, whereas our NSQIP-based analysis provides more temporally specific insight by focusing on the immediate 30-day post-operative period.
The present study thus sought to address this gap by specifically evaluating short-term outcomes of elective TSA in patients with cognitive impairment. This study found that the overall prevalence of dementia or cognitive impairment among TSA patients is 3.6%, a rate comparable to those reported by Serna et al (3.0%) and Bot et al (1.5% for dementia only, excluding milder degrees of cognitive impairment).4,29
An important finding of this study is that patients with dementia or cognitive impairment are more likely to have minor medical complications in the immediate 30-day period following TSA, especially bleeding that requires transfusion. This can be compared to Serna et al, who found that patients with neurocognitive impairment had elevated odds of major medical complications, including acute myocardial infarction and cerebrovascular accident in the 2 years following surgery.29 This suggests that more severe complications may emerge later in patients with cognitive impairment undergoing TSA. Several factors may explain this higher risk of medical complications in cognitively impaired patients undergoing TSA. These patients have a higher burden of medical comorbidities, are more likely to be frail, and often present with unrecognized or undertreated conditions such as anemia and malnutrition.22,26,33,36,39 These factors all contribute to increase the risk of perioperative complications and transfusion requirements after TSA, as demonstrated by multivariable analyses identifying frailty, malnutrition, higher ASA class, low pre-operative hematocrit, and comorbidities as key predictors of bleeding and transfusion.1,3,6,13,21,31,35 While we adjusted for ASA class and several major comorbidities in our analysis, patients with dementia and these risk factors may have had suboptimal ability to ensure proper pre-operative optimization of these conditions. Additionally, patients with dementia or cognitive impairment are at increased risk for post-operative delirium, which can precipitate agitation, hemodynamic instability, and increased risk of falls or inadvertent removal of lines, further contributing to medical complications, including bleeding requiring transfusion.7,20,23,28
Another key finding was that patients with dementia or cognitive impairment are also more likely to be discharged to a nonhome setting and be readmitted within 30 days, even after adjusting for pre-operative dependent functional status. This could be due to several factors, including impaired ability to follow post-operative instructions, increased risk of delirium, greater need for supervision, and limited capacity to safely manage self-care and rehabilitation at home.2,14,18,37 The cumulative effect of these vulnerabilities results in patients with dementia or cognitive impairment being at higher risk for short-term complications after elective TSA. To mitigate these risks, patients with dementia or cognitive impairment should undergo careful pre-operative optimization as well as early and comprehensive discharge and rehabilitation planning before undergoing elective TSA. This could include patient and caregiver education before surgery, including instruction on post-operative exercises, modifications to activities of daily living, and planning for additional post-operative assistance and home environment adjustments.8,17,27 Special consideration should be given to modifiable risk factors including correcting pre-operative anemia, optimizing nutrition, and managing polypharmacy.25,30,40 Early involvement of case management and social work in combination with early identification of patients at high risk for nonhome discharge can help facilitate appropriate discharge placement. Lastly, post-operative rehabilitation protocols should be tailored to cognitive status, emphasizing clear, simple instructions, and caregiver involvement.32
This study should be interpreted in light of several limitations. First, the substantial number of patients excluded due to missing baseline data and during subsequent 5:1 propensity score matching may have introduced selection bias and reduced the representativeness of the final analytic cohort, thereby limiting generalizability. However, findings were consistent in both the propensity-matched analysis and the multivariable full-cohort sensitivity analysis, supporting the robustness of the observed associations. Second, as with all large administrative datasets, NSQIP is subject to coding inaccuracies and data entry errors, which may lead to misclassification of dementia diagnoses or post-operative complications. Another limitation is that NSQIP only captures outcomes within 30 days post-operatively, limiting assessment of long-term complications such as implant failure, loosening, periprosthetic fracture, or revision surgery, as well as functional recovery and mortality beyond this period. Furthermore, NSQIP does not provide the granularity to determine which patients received an anatomic TSA or reverse TSA. In addition, NSQIP does not offer detailed clinical information such as the severity of cognitive impairment, specific implant type, surgical technique, anesthesia management, or surgeon experience, all of which may influence outcomes after TSA. Important patient-level context, especially for those with dementia or cognitive impairment, such as living situation and social support, is also not available. Finally, as NSQIP represents only participating hospitals, there may be selection bias that limits the generalizability of our findings to all U.S. institutions. Nonetheless, the strengths of the NSQIP database include its large, nationally representative cohort with prospectively collected and standardized clinical data, which allows for robust risk-adjusted analyses.
Conclusion
Cognitive impairment is associated with worse 30-day post-operative outcomes following TSA, leading to both immediate risk and overall health burden. Therefore, in light of a pre-operative dementia diagnosis, surgeons should consider tailored care and incorporate cognitive status into pre- and post-operative management. Further studies are needed to identify modifiable risk factors linked to cognitive impairment in orthopedic surgery.
Disclaimers:
Funding: No funding was disclosed by the authors.
Conflicts of interest: Outside of this work, Umasuthan Srikumaran serves as a board or committee member for AAOS, American Shoulder and Elbow Surgeons, and IASES; reports stock or stock options from ROM3, Sonogen, and Tigon Medical; is a paid consultant for and receives intellectual property royalties from Fx Shoulder and Tigon Medical; receives other financial or material support from Arthrex, DePuy–a Johnson & Johnson Company, and Thieme; and has been a paid presenter or speaker for and received research support from Fx Shoulder. Any additional authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
Footnotes
Because this was a retrospective analysis of a publicly available, deidentified national database, it did not require institutional review board approval.
References
- 1.Alder K.D., Yu K.E., Rode M.M., Marigi I.M., Marigi E.M., Morrey M.E., et al. Increasing severity of preoperative anemia is associated with higher postoperative medical and surgical complications after primary shoulder arthroplasty. J Shoulder Elbow Surg. 2024;33:1243–1253. doi: 10.1016/j.jse.2023.10.005. [DOI] [PubMed] [Google Scholar]
- 2.Anderson T.S., Marcantonio E.R., McCarthy E.P., Ngo L., Schonberg M.A., Herzig S.J. Association of diagnosed dementia with post-discharge mortality and readmission among hospitalized medicare beneficiaries. J Gen Intern Med. 2022;37:4062–4070. doi: 10.1007/s11606-022-07549-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Anthony C.A., Westermann R.W., Gao Y., Pugely A.J., Wolf B.R., Hettrich C.M. What are risk factors for 30-day morbidity and transfusion in total shoulder arthroplasty? A review of 1922 cases. Clin Orthop Relat Res. 2015;473:2099–2105. doi: 10.1007/s11999-014-4107-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Bot A.G.J., Menendez M.E., Neuhaus V., Ring D. The influence of psychiatric comorbidity on perioperative outcomes after shoulder arthroplasty. J Shoulder Elbow Surg. 2014;23:519–527. doi: 10.1016/j.jse.2013.12.006. [DOI] [PubMed] [Google Scholar]
- 5.Cecora A.J., Ragland D., Vallurupalli N., Ben-Ari E., Xu J.J., Molokwu B.O., et al. Projections of utilization of primary and revision shoulder arthroplasty in the United States in the next 40 years. JSES Int. 2025;9:472–476. doi: 10.1016/j.jseint.2024.10.013. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Chalmers P.N., Gupta A.K., Rahman Z., Bruce B., Romeo A.A., Nicholson G.P. Predictors of early complications of total shoulder arthroplasty. J Arthroplasty. 2014;29:856–860. doi: 10.1016/j.arth.2013.07.002. [DOI] [PubMed] [Google Scholar]
- 7.Chen L., Au E., Saripella A., Kapoor P., Yan E., Wong J., et al. Postoperative outcomes in older surgical patients with preoperative cognitive impairment: a systematic review and meta-analysis. J Clin Anesth. 2022;80 doi: 10.1016/j.jclinane.2022.110883. [DOI] [PubMed] [Google Scholar]
- 8.Churchill J.L., Paez C.J., Entezari V., Ricchetti E.T., Ho J.C. Understanding medical optimization for patients undergoing shoulder arthroplasty. Orthop Clin North Am. 2023;54:309–318. doi: 10.1016/j.ocl.2023.02.004. [DOI] [PubMed] [Google Scholar]
- 9.Culley D.J., Flaherty D., Fahey M.C., Rudolph J.L., Javedan H., Huang C.-C., et al. Poor performance on a preoperative cognitive screening test predicts postoperative complications in older orthopedic surgical patients. Anesthesiology. 2017;127:765–774. doi: 10.1097/ALN.0000000000001859. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.D’Apuzzo M.R., Pao A.W., Novicoff W.M., Browne J.A. Age as an independent risk factor for postoperative morbidity and mortality after total joint arthroplasty in patients 90 years of age or older. J Arthroplasty. 2014;29:477–480. doi: 10.1016/j.arth.2013.07.045. [DOI] [PubMed] [Google Scholar]
- 11.Edusei E., Kim K.Y., Anoushiravani A.A., Yu S., Steiger D., Slover J.D. Prevalence of neurocognitive dysfunction and its effects on postoperative outcomes in total joint arthroplasty. J Arthroplasty. 2018;33:350–354. doi: 10.1016/j.arth.2017.09.008. [DOI] [PubMed] [Google Scholar]
- 12.Ferri C.P., Prince M., Brayne C., Brodaty H., Fratiglioni L., Ganguli M., et al. Global prevalence of dementia: a Delphi consensus study. Lancet. 2005;366:2112–2117. doi: 10.1016/S0140-6736(05)67889-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Garcia G.H., Fu M.C., Dines D.M., Craig E.V., Gulotta L.V. Malnutrition: a marker for increased complications, mortality, and length of stay after total shoulder arthroplasty. J Shoulder Elbow Surg. 2016;25:193–200. doi: 10.1016/j.jse.2015.07.034. [DOI] [PubMed] [Google Scholar]
- 14.Greysen S.R., Harrison J.D., Kripalani S., Vasilevskis E., Robinson E., Metlay J., et al. Understanding patient-centred readmission factors: a multi-site, mixed-methods study. BMJ Qual Saf. 2017;26:33–41. doi: 10.1136/bmjqs-2015-004570. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Hu C., Liao C., Chang C., Wu C., Chen T. Postoperative adverse outcomes in surgical patients with dementia: a retrospective cohort study. World J Surg. 2012;36:2051–2058. doi: 10.1007/s00268-012-1609-x. [DOI] [PubMed] [Google Scholar]
- 16.Johnson A.H., Brennan J.C., King P.J., Turcotte J.J., MacDonald J.H. Comparison of postoperative outcomes of patients undergoing total hip and total knee arthroplasty following a diagnosis of dementia: a TriNetX database study. Arthroplast Today. 2024;27 doi: 10.1016/j.artd.2024.101359. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Kennedy J.S., Garrigues G.E., Pozzi F., Zens M.J., Gaunt B., Phillips B., et al. The American Society of Shoulder and Elbow Therapists’ consensus statement on rehabilitation for anatomic total shoulder arthroplasty. J Shoulder Elbow Surg. 2020;29:2149–2162. doi: 10.1016/j.jse.2020.05.019. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Knox S., Downer B., Haas A., Middleton A., Ottenbacher K.J. Function and caregiver support associated with readmissions during home health for individuals with dementia. Arch Phys Med Rehabil. 2020;101:1009–1016. doi: 10.1016/j.apmr.2019.12.021. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Krishnan S., Brovman E.Y., Urman R.D. Preoperative cognitive impairment as a perioperative risk factor in patients undergoing total knee arthroplasty. Geriatr Orthop Surg Rehabil. 2021;12 doi: 10.1177/21514593211004533. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Lander H.L., Dick A.W., Joynt Maddox K.E., Oldham M.A., Fleisher L.A., Mazzeffi M., et al. Postoperative delirium in older adults undergoing noncardiac surgery. JAMA Netw Open. 2025;8 doi: 10.1001/jamanetworkopen.2025.19467. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Lawand J.J., Rizk A.A., Sogbein O.A., Granruth C., Ghali A., Hill B.W., et al. Preoperative malnutrition is associated with increased risk of 90-day major medical complications and increased 2-year revision rates following total shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34:e1151–e1158. doi: 10.1016/j.jse.2025.03.005. [DOI] [PubMed] [Google Scholar]
- 22.Loda I., D’Angelo E., Marzetti E., Kerminen H. Prevention, assessment, and management of malnutrition in older adults with early stages of cognitive disorders. Nutrients. 2024;16:1566. doi: 10.3390/nu16111566. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Marcantonio E.R. Delirium in hospitalized older adults. N Engl J Med. 2017;377:1456–1466. doi: 10.1056/NEJMcp1605501. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Mayfield C.K., Korber S.S., Hwang N.M., Bolia I.K., Gamradt S.C., Weber A.E., et al. Volume, indications, and number of surgeons performing reverse total shoulder arthroplasty continue to expand: a nationwide cohort analysis from 2016-2020. JSES Int. 2023;7:827–834. doi: 10.1016/j.jseint.2023.05.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Mueller M.M., Van Remoortel H., Meybohm P., Aranko K., Aubron C., Burger R., et al. Patient blood management: recommendations from the 2018 Frankfurt consensus conference. JAMA. 2019;321:983. doi: 10.1001/jama.2019.0554. [DOI] [PubMed] [Google Scholar]
- 26.Perry E., Walton K., Lambert K. Prevalence of malnutrition in people with dementia in long-term care: a systematic review and meta-analysis. Nutrients. 2023;15:2927. doi: 10.3390/nu15132927. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Polio W., Brolin T.J. Postoperative rehabilitation after shoulder arthroplasty. Phys Med Rehabil Clin North Am. 2023;34:469–479. doi: 10.1016/j.pmr.2022.12.010. [DOI] [PubMed] [Google Scholar]
- 28.Robinson T.N., Raeburn C.D., Tran Z.V., Angles E.M., Brenner L.A., Moss M. Postoperative delirium in the elderly: risk factors and outcomes. Ann Surg. 2009;249:173–178. doi: 10.1097/SLA.0b013e31818e4776. [DOI] [PubMed] [Google Scholar]
- 29.Serna J., Su F., Lansdown D.A., Feeley B.T., Ma C.B., Zhang A.L. Total shoulder arthroplasty in patients with dementia or mild cognitive impairment. JSES Int. 2024;8:159–166. doi: 10.1016/j.jseint.2023.09.004. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Sieber F., McIsaac D.I., Deiner S., Azefor T., Berger M., Hughes C., et al. 2025 American Society of anesthesiologists practice advisory for perioperative care of older adults scheduled for inpatient surgery. Anesthesiology. 2025;142:22–51. doi: 10.1097/ALN.0000000000005172. [DOI] [PubMed] [Google Scholar]
- 31.Silvestre J., Bennett Z.T., Moore J.W., Guareschi A.S., Rogalski B.L., Eichinger J.K., et al. Frailty is associated with increased complication, readmission, and hospitalization costs following primary total shoulder arthroplasty. J Shoulder Elbow Surg. 2025;34:1819–1825. doi: 10.1016/j.jse.2024.10.004. [DOI] [PubMed] [Google Scholar]
- 32.Smith T.O., Gilbert A.W., Sreekanta A., Sahota O., Griffin X.L., Cross J.L., et al. Enhanced rehabilitation and care models for adults with dementia following hip fracture surgery. Cochrane Database Syst Rev. 2020;2 doi: 10.1002/14651858.CD010569.pub3. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Soraci L., De Vincentis A., Aucella F., Fabbietti P., Corsonello A., Arena E., et al. Prevalence, risk factors, and treatment of anemia in hospitalized older patients across geriatric and nephrological settings in Italy. Sci Rep. 2024 Aug 24;14 doi: 10.1038/s41598-024-70644-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Wagner E.R., Farley K.X., Higgins I., Wilson J.M., Daly C.A., Gottschalk M.B. The incidence of shoulder arthroplasty: rise and future projections compared with hip and knee arthroplasty. J Shoulder Elbow Surg. 2020;29:2601–2609. doi: 10.1016/j.jse.2020.03.049. [DOI] [PubMed] [Google Scholar]
- 35.Wang K.Y., Quan T., Gu A., Best M.J., Stadecker M., Srikumaran U. Increased severity of anemia is associated with postoperative complications following primary total shoulder arthroplasty. J Shoulder Elbow Surg. 2021;30:2393–2400. doi: 10.1016/j.jse.2021.01.022. [DOI] [PubMed] [Google Scholar]
- 36.Ward D.D., Flint J.P., Littlejohns T.J., Foote I.F., Canevelli M., Wallace L.M.K., et al. Frailty trajectories preceding dementia in the US and UK. JAMA Neurol. 2025;82:61. doi: 10.1001/jamaneurol.2024.3774. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37.Weiss Y., Zac L., Refaeli E., Ben-Yishai S., Zegerman A., Cohen B., et al. Preoperative cognitive impairment and postoperative delirium in elderly surgical patients: a retrospective large cohort Study (the CIPOD Study) Ann Surg. 2023;278:59–64. doi: 10.1097/SLA.0000000000005657. [DOI] [PubMed] [Google Scholar]
- 38.Wong S.E., Colley A.K., Pitcher A.A., Zhang A.L., Ma C.B., Feeley B.T. Mental health, preoperative disability, and postoperative outcomes in patients undergoing shoulder arthroplasty. J Shoulder Elbow Surg. 2018;27:1580–1587. doi: 10.1016/j.jse.2018.02.066. [DOI] [PubMed] [Google Scholar]
- 39.Ye X., Wang X., Hu M., Ouyang Y. Frailty and risks of dementia among middle-aged and older adults: evidence from 3 prospective cohort studies. Am J Prev Med. 2025;69 doi: 10.1016/j.amepre.2025.108088. [DOI] [PubMed] [Google Scholar]
- 40.Zink T.M., Kent S.E., Choudhary A.N., Kavolus J.J. Nutrition in surgery: an orthopaedic perspective. J Bone Joint Surg. 2023;105:1897–1906. doi: 10.2106/JBJS.23.00259. [DOI] [PubMed] [Google Scholar]