Incidence of Postoperative Delirium and Its Impact on Outcomes After Transcatheter Aortic Valve Implantation

Does Comprehensive Geriatric Assessment Reduce the Incidence of Postoperative Delirium? A Quasi-experimental Study in Older Adults Undergoing Transcatheter Aortic Valve Implantation

Purpose

Postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) is frequent in older adults and associated with multiple negative outcomes including a higher mortality. We aimed to investigate whether a comprehensive geriatric assessment (CGA) prior to TAVI reduces the odds of POD and results in a positive change in self-care ability, intended to lay a foundation for future geriatric comanagement.

Patients and methods

We used a retrospective, single-center study with a quasi-experimental design enrolling patients aged 70 years and older undergoing CGA before elective TAVI, and a nonrandomized comparison group without preoperative CGA. Data on POD occurrence during the first 5 days after TAVI (primary outcome) and change in self-care ability index (SPI) between admission and discharge (secondary outcome) were collected from electronic health records and CGA data (exposure) by clinical assessment. To explore associations between (1) CGA and POD, and (2) CGA and SPI, multivariate logistic regression and linear regression models were applied adjusting for age, sex, BMI, and number of medications.

Results

Among 435 patients (mean age 81.0 ± 5.6 years, 43.6% women, median [IQR] SPI at baseline 40 [39, 40] points), POD incidence was 14.3% in the CGA group vs 18.8% in the non-CGA group (P 0.219). Undergoing CGA before TAVI was not associated with the odds for POD (OR: 1.15; 95%CI: 0.65-2.04) or improved SPI (P 0.073).

Conclusion

We observed no association of CGA prior to TAVI with POD incidence or postoperative self-care, highlighting the need for additional studies investigating the effect of POD preventive measures in older TAVI patients integrated into a comprehensive geriatric comanagement program.

Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients

Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.

Association of general anesthesia exposure with risk of postoperative delirium in patients receiving transcatheter aortic valve replacement: a meta-analysis and systematic review

The aim of this meta-analysis was to assess the association of general anesthesia (GA) exposure with the risk of POD in this patient population. Databases including Medline, EMBASE, Cochrane library, and Google Scholar were searched from inception to December 2022. Analysis of 17 studies published between 2015 and 2021 involving 10,678 individuals revealed an association of GA exposure with an elevated risk of POD [odd ratio (OR) = 1.846, 95% CI 1.329 to 2.563, p = 0.0003, I2 = 68.4%, 10,678 patients]. Subgroup analysis of the diagnostic methods also demonstrated a positive correlation between GA exposure and POD risk when validated methods were used for POD diagnosis (OR = 2.199, 95% CI 1.46 to 3.31, p = 0.0002). Meta-regression analyses showed no significant impact of age, male proportion, and sample size on the correlation between GA and the risk of POD. The reported overall incidence of POD from the included studies regardless of the type of anesthesia was between 0.8 and 27%. Our meta-analysis showed a pooled incidence of 10.3% (95% CI 7% to 15%). This meta-analysis suggested an association of general anesthesia with an elevated risk of postoperative delirium, implying the necessity of implementing appropriate prophylactic strategies against this complication when general anesthesia was used in this clinical setting.

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis

BACKGROUND

With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over.

METHODS

Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed.

RESULTS

A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted.

LINKING EVIDENCE TO ACTION

This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.

Asymptomatic Aortic Stenosis in an Older Patient: How the Geriatric Approach Can Make a Difference

We present a case report of an older patient with aortic stenosis who was managed before and after transcatheter aortic valve implantation by a team of cardiologists but without the support of a geriatrician. We first describe the patient's post-interventional complications from a geriatric perspective and afterwards, discuss the unique approach that the geriatrician would have provided. This case report was written by a group of geriatricians working in an acute hospital, along with a clinical cardiologist who is an expert in aortic stenosis. We discuss the implications for modifying conventional practice in tandem with existing literature.

Postoperative delirium after transcatheter aortic valve replacement: An updated systematic review and meta-analysis

AIMS

To perform an updated systematic review and meta-analysis of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

METHODS

We conducted a systematic literature search of PubMed, Embase, and Cochrane Library databases from the time of the first human TAVR procedure in 2002 until December 24, 2021, which was supplemented by manual searches of bibliographies. Data were collected on incidence rates, risk factors, and/or associated mortality of POD after TAVR. Pooled analyses were conducted using random effects models to yield mean differences, odds ratios, hazard ratios, and risk ratios, with 95% confidence intervals.

RESULTS

A total of 70 articles (69 studies) comprising 413,389 patients were included. The study heterogeneity was substantial. The pooled mean incidence of POD after TAVR in all included studies was 9.8% (95% CI: 8.7%-11.0%), whereas that in studies using validated tools to assess for delirium at least once a day for at least 2 consecutive days after TAVR was 20.7% (95% CI: 17.8%-23.7%). According to the level of evidence and results of meta-analysis, independent preoperative risk factors with a high level of evidence included increased age, male sex, prior stroke or transient ischemic attack, atrial fibrillation/flutter, weight loss, electrolyte abnormality, and impaired Instrumental Activities of Daily Living; intraoperative risk factors included non-transfemoral access and general anesthesia; and acute kidney injury was a postoperative risk factor. POD after TAVR was associated with significantly increased mortality (pooled unadjusted RR: 2.20, 95% CI: 1.79-2.71; pooled adjusted RR: 1.62, 95% CI: 1.25-2.10), particularly long-term mortality (pooled unadjusted HR: 2.84, 95% CI: 1.91-4.23; pooled adjusted HR: 1.88, 95% CI: 1.30-2.73).

CONCLUSIONS

POD after TAVR is common and is associated with an increased risk of mortality. Accurate identification of risk factors for POD after TAVR and implementation of preventive measures are critical to improve prognosis.

Outcomes of postoperative delirium in patients undergoing cardiac surgery: A systematic review and meta-analysis

Background

Postoperative delirium (POD) is an acute brain dysfunction that is frequently observed in patients undergoing cardiac surgery. Increasing evidence indicates POD is related to higher mortality among cardiac surgical patients, but the results remain controversial. Moreover, a quantitative evaluation of the influence of POD on hospital days, intensive care unit (ICU) time, and mechanical ventilation (MV) time has not been performed.

Objective

This study aimed to evaluate the correlation between POD and outcomes in patients undergoing cardiac surgery by a systematic review and meta-analysis.

Materials and methods

A total of 7 electronic databases (Cochrane Library, PubMed, EMBASE, CINAHL Complete, MEDLINE, Wan-fang database, and China National Knowledge Infrastructure) were searched from January 1980 to July 20, 2021, with language restrictions to English and Chinese, to estimate the impact of the POD on outcome in patients who underwent cardiac surgery. The meta-analysis was registered with PROSPERO (Registration: CRD42021228767).

Results

Forty-two eligible studies with 19785 patients were identified. 3368 (17.0%) patients were in the delirium group and 16417 (83%) were in the non-delirium group. The meta-analysis showed that compared to patients without POD, patients with POD had 2.77-fold higher mortality (OR = 2.77, 95% CI 1.86-4.11, P < 0.001), 5.70-fold higher MV (>24h) rate (OR = 5.70, 95% CI 2.93-11.09, P < 0.001); and longer MV time (SMD = 0.83, 95% CI 0.57-1.09, P < 0.001), ICU time (SMD = 0.91, 95% CI 0.60-1.22, P < 0.001), hospital days (SMD = 0.62, 95% CI 0.48-0.76, P < 0.001).

Conclusion

The synthesized evidence suggests that POD is causally related to the increased risk of mortality, prolonged length of ICU and hospital stay, and a longer duration of MV time. Future research should focus on the interventions for POD, to reduce the incidence.

Systematic review registration

[www.crd.york.ac.uk/PROSPERO], identifier [CRD42021228767].

Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review

Silent brain infarctions (SBIs) are brain lesions noted on neuroimaging that are not associated with clinical symptoms. SBIs are associated with a number of vascular risk factors and are common following invasive cardiovascular procedures such as atrial fibrillation (AF) ablation, coronary artery bypass graft (CABG), and transcatheter aortic valve replacement (TAVR). Although not eliciting signs of clinical stroke, SBIs are associated with increased frailty, and motor and mood features. Less is known, however, about the relationship between SBI, cognition, and delirium following invasive cardiac procedures and most investigations into these relationships have been reported in large-scale epidemiological studies. In the current paper, we conducted a systematic review to evaluate evidence of a relationship between SBI, delirium, and cognitive decline following CABG, AF ablation, and TAVR. Twenty studies met inclusion criteria. In general, our review identified conflicting results for each cardiac procedure, with some studies suggesting a relationship between SBI, cognitive impairment, and delirium, whereas others showed no relationship between SBI, cognitive impairment, and delirium. Potential reasons for this discrepancy as well as suggestions for future research are discussed.

Investigation of Risk Factors for Postoperative Delirium after Transcatheter Aortic Valve Implantation: A Retrospective Study

Transcatheter aortic valve implantation (TAVI) is an effective treatment for severe aortic stenosis (AS); however, postoperative delirium (POD) can worsen patient outcomes. This study aimed to examine the risk factors for POD after TAVI, including possible intervening factors. We included 87 patients (mean age: 83) who underwent TAVI between May 2014 and September 2018. POD was defined by the presence or absence of delirium on ICU admission, assessed using the Confusion Assessment Method for the ICU. Factors that showed significant differences in the univariate analysis were analyzed using a multiple logistic regression analysis. In total, 31 patients (36%) had POD after ICU admission, and 56 (64%) did not. The preoperative frailty score and aortic valve opening area (AVA) were significant risk factors for POD. The multivariate analysis also showed that both factors were independent risk factors for POD (area under the receiver operating characteristic curve: 0.805). There were no significant differences in the number of ICU days. However, postoperative hospitalization was significantly longer in the POD group (19 (17–31) days vs. 16 (13–22) days; p = 0.002). POD was associated with a narrow AVA and frailty; this suggests that frailty prevention interventions according to the AVA may be important.

Postoperative delirium and quality of life after transcatheter and surgical aortic valve replacement: A prospective observational study

OBJECTIVE

In older patients, postoperative delirium is a frequently occurring complication after surgical aortic valve replacement, leading to an excess in postoperative morbidity and mortality. It remains controversial whether transcatheter aortic valve implantation and minimally invasive surgical aortic valve replacement can reduce the risk of postoperative delirium. This study aimed to compare the incidence of postoperative delirium after transcatheter aortic valve implantation and surgical aortic valve replacement and the impact on long-term outcomes.

METHODS

Between September 2018 and January 2020, we conducted an observational, prospective cohort study in patients aged 70 years or more undergoing transcatheter aortic valve implantation or surgical aortic valve replacement. The primary end point was the incidence of in-hospital postoperative delirium during 5 postoperative days assessed with the Confusion Assessment Method. Secondary end points included perioperative inflammation, postoperative complications, health status (EuroQol 5-dimensional questionnaire 5 levels), and mortality up to 6 months. Transcatheter aortic valve implantation and surgical aortic valve replacement were compared using propensity weighting to account for important baseline differences (European System for Cardiac Operative Risk Evaluation II, age, and frailty).

RESULTS

We included 250 patients with a mean (standard deviation) age of 80 (±5.8) years and a European System for Cardiac Operative Risk Evaluation score of 5 (±4.7). In the propensity-weighted analysis, those undergoing surgical aortic valve replacement (N = 166) had a higher incidence of postoperative delirium compared with transcatheter aortic valve implantation (N = 84) (51% vs 15%: P < .0001). Furthermore, patients undergoing surgical aortic valve replacement experienced more inflammation, a greater depth of anesthesia, and more intraoperative hypotension. After surgical aortic valve replacement, 41% of patients experienced an improved health status compared with 12% after transcatheter aortic valve implantation (P < .0001). No outcome differences were noted within the surgical aortic valve replacement groups.

CONCLUSIONS

Transcatheter aortic valve implantation is associated with a lower risk for postoperative delirium. Nevertheless, patients undergoing surgical aortic valve replacement experience the greatest improvement in quality of life. Heart teams should consider these outcomes in shared decision-making in the choice of transcatheter aortic valve implantation or surgical aortic valve replacement.

The Association Between Preoperative Frailty and Postoperative Delirium: A Systematic Review and Meta-analysis

PURPOSE

Identifying factors that place patients at high risk for developing postoperative delirium is an important first step to reduce incidence. Frailty is associated with poor postoperative outcomes. This meta-analysis aims to determine the association between preoperative frailty and postoperative delirium.

DESIGN

This is a systematic review and meta-analysis.

METHODS

We used PubMed, Scopus, Embase, CINAHL, Cochrane, and Web of Science as databases for the search up to April 23, 2020. We included cohort studies that assessed postoperative delirium as the outcome and described the prevalence of delirium among participants during the postoperative period. Odds ratio and 95% confidence interval were calculated to examine the association.

FINDINGS

Twenty cohort studies met our inclusion criteria, which included a total of 4,568 patients. We found that preoperative frailty was significantly associated with an increased risk of postoperative delirium (crude odds ratio: 3.28; 95% confidence interval: 2.51 to 4.28; I² = 46.7%) (adjusted odds ratio: 2.45; 95% confidence interval: 1.58 to 3.81; I² = 88.6%).

CONCLUSIONS

This meta-analysis showed that preoperative frailty is an independent risk factor for postoperative delirium. In patients undergoing cardiovascular surgery, there is a lower association between frailty and postoperative delirium. In patients with other types of surgery, preoperative frailty is closely related to postoperative delirium.

The effect of foot reflexology massage on delirium and sleep quality following cardiac surgery: A randomized clinical trial

BACKGROUND

Delirium is the most common neurologic disorder after cardiac surgery and affects both short and long-term outcomes. This study was conducted to evaluate the effect of foot reflexology massage on the incidence of delirium and sleep quality in patients undergoing cardiac surgery.

METHODS

In this randomized clinical trial, 60 patients who were candidates for CABG surgery were randomly assigned into two equal groups (n = 30); intervention and control groups. In the intervention group, foot reflexology massage was done on each foot for 15 min, for two consecutive days. Delirium observation screening scale, the Richard Campbell sleep questionnaire (RSCQ), and pain intensity using VAS were compared.

RESULTS

in the second postoperative day, delirium was observed in 8 (26.7 %) and 7 (23.3 %) of patients in the intervention and control groups, respectively (p > 0.05). The measured odds ratio for the effect of massage on delirium is 0.83 (95 %CI 0.71-2.69, p = 0.76). The difference in RSCQ scores was not significant between groups of intervention and control (68.32 ± 10.41 VS. 62.80 ± 11.86, P = 0.06). The pain intensity was lower in the intervention group (P < 0.001).

CONCLUSION

Foot reflexology was not effective in reducing delirium and improving the sleep quality, but the pain intensity was decreased. It seems that the precise pathology and predicting model of delirium should be identified, and appropriate interventions should be planned accordingly.

Delayed Improvement of Depression and Anxiety after Transcatheter Aortic Valve Implantation (TAVI) in Stages of Extended Extra-Valvular Cardiac Damage

Background: Depression and anxiety are frequently occurring and likely to be linked to the severity of cardiac diseases like aortic stenosis (AS). This seems to be of interest since a staging classification of extra-valvular cardiac damage in AS has been introduced and shown to be of prognostic relevance. Objective: The current study aimed to investigate the frequency of depression and anxiety in association to staging and their dynamics after transcatheter aortic valve implantation (TAVI). Methods: A total number of 224 AS patients undergoing TAVI were classified according to the 2017 staging classification into stage 0 to 4 and further dichotomized into group A (stage 0 to 2) and B (stage 3 and 4). Using the Hospital Anxiety and Depression Scale (HADS-D), patients were assigned to depressive versus non-depressive or anxious versus non-anxious per staging group respectively, and analyzed at baseline, 6 weeks, 6 months and 12 months after TAVI. Results: After dichotomization, 158 patients (70.5%) were assigned to group A and 66 patients (29.5%) to group B. The part showing pathologic values for depression was 25.4% (57/224 patients) in the entire collective, 26.6% (42/158 patients) in group A and 22.7% (15/66 patients) in group B (p = n.s.). The proportion showing pathologic values for anxiety was 26.8% (60/224 patients) in the entire collective and did not differ between group A (24.7%, 39/158 patients) and B (31.8%, 21/66 patients) (p = n.s.). In patients revealing pathologic values for depression or anxiety prior to TAVI, there were significant and stable improvements over time observable already in short-term (6 weeks) follow-up in group A, and likewise, but later, in long-term (6/12 months) follow-up in group B. Conclusions: Although of proven prognostic relevance, higher stages of extra-valvular cardiac damage are not associated with higher rates of pre-existing depression or anxiety. The TAVI procedure resulted in a persisting reduction of depression and anxiety in patients showing pathologic values at baseline. Notably, these improvements are timely delayed in higher stages.

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).

Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test.

Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030].

Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.

Measurement and prognosis of frail patients undergoing transcatheter aortic valve implantation: a systematic review and meta-analysis

OBJECTIVES

Our objectives were to review the literature to identify frailty instruments in use for transcatheter aortic valve implantation (TAVI) recipients and synthesise prognostic data from these studies, in order to inform clinical management of frail patients undergoing TAVI.

METHODS

We systematically reviewed the literature published in 2006 or later. We included studies of patients with aortic stenosis, diagnosed as frail, who underwent a TAVI procedure that reported mortality or clinical outcomes. We categorised the frailty instruments and reported on the prevalence of frailty in each study. We summarised the frequency of clinical outcomes and pooled outcomes from multiple studies. We explored heterogeneity and performed subgroup analysis, where possible. We also used Grading of Recommendations, Assessment, Development and Evaluation (GRADE) to assess the overall certainty of the estimates.

RESULTS

Of 49 included studies, 21 used single-dimension measures to assess frailty, 3 used administrative data-based measures, and 25 used multidimensional measures. Prevalence of frailty ranged from 5.67% to 90.07%. Albumin was the most commonly used single-dimension frailty measure and the Fried or modified Fried phenotype were the most commonly used multidimensional measures. Meta-analyses of studies that used either the Fried or modified Fried phenotype showed a 30-day mortality of 7.86% (95% CI 5.20% to 11.70%) and a 1-year mortality of 26.91% (95% CI 21.50% to 33.11%). The GRADE system suggests very low certainty of the respective estimates.

CONCLUSIONS

Frailty instruments varied across studies, leading to a wide range of frailty prevalence estimates for TAVI recipients and substantial heterogeneity. The results provide clinicians, patients and healthcare administrators, with potentially useful information on the prognosis of frail patients undergoing TAVI. This review highlights the need for standardisation of frailty measurement to promote consistency.

PROSPERO REGISTRATION NUMBER

CRD42018090597.

Six-Minute Walk Test Predicts Postoperative Delirium After Transcatheter Aortic Valve Replacement

OBJECTIVE

This study investigated the incidence and risk factors of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR) and to evaluate the association between preoperative conditions, particularly frailty, and POD.

DESIGN

Observational, case-control study.

SETTING

Single-center university hospital.

PARTICIPANTS

The study comprised 124 patients who underwent TAVR and were divided into the following two groups: group D (patients diagnosed with POD) and group C (patients without POD).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-seven patients (21.7%) developed POD (95% confidence interval 14.9%-30.1%). POD was defined as a diagnosis of delirium using the Confusion Assessment Method for Intensive Care Unit scale during the patients' intensive care unit stay. Preoperative and postoperative data of patient characteristics were obtained from their medical records. A multivariate logistic regression analysis was performed using variables associated with POD incidence. Frailty scores were significantly higher in group D than in group C. The distance covered in the six-minute walk test (6MD) was significantly shorter in group D than in group C. The risk of developing POD was significantly higher in patients with a 6MD shorter than 220 m. Multivariate logistic regression analysis showed that a shorter 6MD was an independent risk factor for POD (odds ratio 5.66; p = 0.004).

CONCLUSION

In the present study, POD was seen in 21.7% of the patients who underwent TAVR. A 6MD shorter than 220 m was an independent preoperative risk factor for POD. For patients at high risk of POD, more careful management in the perioperative period may reduce POD.

Preventative effects of ramelteon against postoperative delirium after elective liver resection

Background

Postoperative delirium was reported to be associated with increased postoperative mortality after liver resection. Therefore, it is crucial to prevent postoperative delirium in such cases. Ramelteon, an agonist of melatonin receptor has been suggested to be useful for preventing delirium. The aim of this study was to examine whether ramelteon is effective at preventing delirium after elective liver resection.

Methods

The cases of patients who underwent liver resection at Nara Medical University (Nara, Japan) between January 2014 and August 2018 were analyzed. During the period from January 2017 to August 2018, ramelteon was prospectively administered to patients who underwent liver resection [8 mg/day on the day before surgery and on postoperative days 1 to 3] (ramelteon group), whereas ramelteon was not administered during the period from January 2014 to December 2016 (control group). The perioperative outcomes of the two groups were compared.

Results

There were 120 patients in the ramelteon group and 186 patients in the control group. No significant intergroup differences in background factors, including age, gender, and preoperative serological laboratory data, were detected. The incidence of postoperative delirium was significantly lower in the ramelteon group (5.8% vs. 15.1%, P = 0.035). Multivariate analysis revealed that being aged ≥75 (P = 0.002), being male (P = 0.020), cardiovascular disease (P = 0.023), blood loss ≥1000ml (P = 0.001) and the absence of ramelteon treatment (P = 0.046) were independent risk factors for postoperative delirium.

Conclusion

The administration of ramelteon might reduce the risk of postoperative delirium after elective liver resection.

A call to action for delirium research: Meta-analysis and regression of delirium associated mortality

Background

Delirium is an extremely common hospital complication. No study to date has assessed whether a priori defined covariates; type of hospital setting and year of study publication, influence the relationship between delirium and mortality. This is also the first study to examine the longitudinal trend of delirium-associated mortality over recent decades, to analyse the trajectory of our efforts in combating this disease.

Methods

MEDLINE, EMBASE and PsycINFO, were searched from January 1981 to May 2018 for English-language primary articles. Rigorous title and abstract screen and full-text screen were conducted independently by two reviewers. This paper adhered to MOOSE guidelines. Data was extracted independently by one reviewer using standardised data-collection sheets, with a separate reviewer verifying for accuracy. The quality of included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Unadjusted effect sizes and event counts were analysed with a random effects model in primary meta-analysis and meta-regression, whereas a mixed effect model was used in secondary sub-group analysis. Mortality data at longest follow-up and cumulative mortality (hospital mortality combined with mortality at longest follow-up) data were analysed.

Results

As part of a larger project, 446 of 6790 articles were retrieved, including 71 studies that measured mortality. Our results demonstrate that elderly inpatients with delirium had significantly greater odds of mortality (OR 3.18 [95%CI: 2.73, 3.70]) compared to non-delirious controls. Patients with delirium in the ICU had the highest odds for mortality (OR: 7.09 [95%CI: 3.60, 14.0]); double the risk compared to the average. Curiously, despite advancements in delirium research, delirium associated in-hospital odds of mortality has not changed in 30 years.

Conclusion

This is the largest meta-analysis to confirm the association between delirium and mortality, in older (age ≥ 65) hospital inpatients.

The current meta-analysis highlights the significant odds of mortality after an episode of delirium, and these odds are much higher for ICU patients. However, in contrast to other medical conditions that have seen a decrease in associated mortality over the past few decades, delirium associated mortality remains unchanged. These findings underscore the urgent need for better delirium treatments.

PROSPERO Registration Number: CRD42018098627, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=98627

Suvorexant for the prevention of delirium: A meta-analysis

BACKGROUND

Delirium is a frequently encountered complication, which is associated with increased mortality. Suvorexant, an approved agent for the treatment of insomnia, is recently suggested to be also effective for prevention of delirium by some authors. However, a consensus has yet to be reached. The goal of this study was to perform a meta-analysis to overall estimate the effectiveness of suvorexant in preventing delirium and its related consequences.

METHODS

Eligible studies were identified by searching online databases of PubMed, EMBASE, and Cochrane Library. The pooled OR was calculated for binary outcomes (e.g., the incidence of delirium, mortality, or adverse events), while standardized mean difference (SMD) were expressed for continuous outcomes (e.g., time to delirium onset, length of stay in hospital and ICU, time on ventilation).

RESULTS

Seven studies which comprised 402 suvorexant treatment patients and 487 patients with control treatment were included in this meta-analysis. Overall, pooled analysis indicated the incidence of delirium could be significantly reduced (OR, 0.30; P < .001) and time to delirium onset was significantly lengthened (SMD, 0.44; P = .006) in patients undergoing suvorexant treatment compared with controls. Suvorexant had no beneficial effects on the secondary outcomes [length of stay in hospital (SMD, -0.65; P = .161) and ICU (SMD, 0.34; P = .297), time on ventilation (SMD, 1.09; P = .318), drug-related adverse events (OR, drug-related adverse events (OR, 1.66; P = .319) and mortality (OR, 2.21; P = .261)]. Subgroup analysis also confirmed the benefit of suvorexant on the development of delirium, which was significant in any subgroup.

CONCLUSION

Suvorexant should be recommended for the prevention of delirium in clinic.

Preoperative physical performance-related postoperative delirium in patients after cardiovascular surgery

OBJECTIVES

This investigation clarified the relationship between a short physical performance battery (SPPB) that can comprehensively and safely evaluate balance function, walking ability, lower limb muscle strength, and postoperative delirium.

METHODS

This was a retrospective observational study performed at Kobe City Medical Center General Hospital. Patients who underwent surgery at the Kobe City Medical Center General Hospital Cardiovascular Surgery from August 1, 2016 to July 31, 2017 were included. Preoperative physical functions were obtained. Those showing positive results using the confusion assessment method for intensive care unit (ICU) during the ICU stay were considered as the delirium group, and the postoperative and non-postoperative delirium groups were compared. A multiple logistic regression analysis was performed with the presence or absence of onset of delirium as the dependent variable and the SPPB total score and age as dependent variables.

RESULTS

There were 193 subjects in this study (120 males and 73 females). Sixteen patients (8.4 %) had postoperative delirium. The age in the postoperative delirium group was significantly higher than in the postoperative delirium group (77.8 (7.0) years vs. 70.0 (11.1) years). BMI and SPPB total score were significantly lower in the postoperative delirium group. From the multiple logistic regression, the SPPB total score (OR: 0.754, 95 % CI: 0.643-0.883, p < 0.001) was extracted as a factor related to postoperative delirium onset.

CONCLUSION

It was illuminated that in patients with cardiovascular surgery, preoperative low physical function was not affected by age and became a risk factor of postoperative delirium onset.

Incidence, determinants and consequences of delirium in older patients after transcatheter aortic valve implantation

BACKGROUND

delirium is an event leading to negative health outcomes and increased mortality in patients. The aim of this study is to investigate the incidence, determinants and consequences of post-operative delirium (POD) in older patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

The TAVI Care and Cure program is a prospective, observational registry in patients referred for TAVI at Erasmus University Medical Centre. The presence of delirium was evaluated by daily clinical assessment by a geriatrician pre- and up to 3 days post-TAVI. Mortality data were obtained from the Dutch Civil Registry.

RESULTS

A total of 543 patients underwent TAVI between January 2014 and December 2017. Overall, the incidence of POD was 14% (75/543 patients) but declined from 18% in 2014 to 7% in 2017 (P = 0.009). Patients who developed POD were older (81.9 ± 5.8 versus 78.6 ± 8.3 years, P < 0.001), had higher prevalence of renal dysfunction and prior stroke (54% versus 40%, P = 0.02; 31% versus 18%, P = 0.01) and were more often frail (32% versus 25%, P = 0.02). From a procedural perspective, general anesthesia (odds ratios (OR), 2.31; 95% CI, 1.40-3.83; P = 0.001), non-transfemoral access (OR, 2.37; 95% CI, 1.20-4.70; P = 0.01) and longer procedural time (OR, 1.01; 95% CI, 1.01-1.02; P < 0.001) were significantly associated with POD. One-year survival rate was 68% among patients who had suffered a POD and was 85% in patients without a POD (hazard ratio's 1.8 (95% CI 1.01-3.10), P = 0.045).

CONCLUSION

POD frequently occurs after TAVI and is associated with increased mortality. It might be speculated that patient selection and the minimalistic approach of TAVI may reduce the frequency of delirium.

Changes in cognitive functions and quality of life in patients after transcatheter aortic valve implantation

Introduction

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for patients with severe aortic stenosis (AS). However, an association between cognitive functions (CF) and health-related quality of life (HRQoL) in TAVI patients is still unclear.

Aim

To assess the long-term changes in CF and HRQoL in elderly patients with AS after TAVI.

Material and methods

A total of 259 patients who underwent cardiological and psychological TAVI qualification were enrolled and divided into the normal (n = 174) and impaired cognition group (n = 85). CF and HRQoL characteristics assessed at baseline and 13 months were compared between groups. The analysis of multiple linear regression was performed to identify the association between HRQoL and CF and to assess the influence of TAVI on HRQoL.

Results

There was no difference in CF between baseline and follow-up. However, an improvement in attention functions and memory skills in the cognitively impaired group was noted at follow-up. In addition, HRQoL scores increased in both groups. An independent predictor associated with HRQoL was global CF (β = –213, p = 0.01), which explained 7% of CF variation. Improvements in all five dimensions of HRQoL, from 4.8% in self-care and up to 33.6% in pain/discomfort, were found. At follow-up, 60% of TAVI patients had improved health, 12% had worse health, 4% showed no change and 24% had a “mixed” change.

Conclusions

TAVI is associated with positive changes in the functioning of elderly patients at long-term follow-up.

Early mobilisation after transfemoral transcatheter aortic valve implantation: results of the MobiTAVI trial

Background

Immobilisation of patients after transfemoral transcatheter aortic valve implantation (TF-TAVI) is the standard of care, mostly to prevent vascular complications. However, immobilisation may increase post-operative complications such as delirium and infections. In this trial, we determine whether it is feasible and safe to implement early ambulation after TF-TAVI.

Methods

We prospectively included TF-TAVI patients from 2016 to 2018. Patients were assessed for eligibility using our strict safety protocol and were allocated (based on the time at which the procedure ended) to the EARLY or REGULAR group.

Results

A total of 150 patients (49%) were deemed eligible for early mobilisation, of which 73 were allocated to the EARLY group and 77 to the REGULAR group. The overall population had a mean age of 80 years, 48% were male with a Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) score of 3.8 ± 1.8. Time to mobilisation was 4 h 49 min ± 31 min in the EARLY group versus 20 h 7 min ± 3 h 6 min in the REGULAR group (p < 0.0001). There were no differences regarding the primary endpoint. No major vascular complications occurred and a similar incidence of minor vascular complications was seen in both groups (4/73 [5.5%] vs 6/77 [7.8%], p = 0.570). The incidence of the combined secondary endpoint was lower in the EARLY group (p = 0.034), with a numerically lower incidence for all individual outcomes (delirium, infections, pain and unplanned urinary catheter use).

Conclusion

Early mobilisation (ambulation 4–6 h post-procedure) of TF-TAVI patients is feasible and safe. Early ambulation decreases the combined incidence of delirium, infections, pain and unplanned urinary catheter use, and its adoption into contemporary TAVI practice may therefore be beneficial.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01374-5) contains supplementary material, which is available to authorized users.

Functional impairment assessed by the Barthel Index influenced outcomes after transcatheter aortic valve implantation

Objective. We investigated the influence of functional impairment assessed by the Barthel index (BI) on the three-month outcomes after transfemoral-transcatheter aortic valve intervention (TF-TAVI) under general anesthesia. Design. We included retrospectively analyzed 336 patients undergoing TAVI between January 2017 and January 2018 in central hospital, Bad Berka, Germany. All patients were followed up at three-month in our center's outpatient clinic. We stratified the patients according to the BI. Results. At baseline, 76 patients had a BI <80. Patients with a BI <80 were characterized by advanced age (80.6 ± 5.6 vs. 83 ± 4.1 years. p = .027), diabetes mellitus on insulin and higher surgical risk scores. A prior cerebral ischemic event was recorded more in patients with a BI ≥80. Regarding intermediate outcomes, three-month mortality was significantly higher in patients with a BI <80. Patients with a BI <80 developed significantly more postoperative cardiac decompensation, delirium and strokes. Patients with BI <80 had lower hemoglobin level preoperative and needed more blood transfusion postoperative. Other valve academic research consortiums (VARCs) complications were equally distributed in both groups. A BI <80 was associated with prolonged postoperative hospital stay and was an independent predictor of FT protocol failure (OR 4; CI 95% 1.3-11. p .02). Conclusions. A BI <80 is associated with increased mortality and risk of neurological events and cardiac decompensations after TF TAVI. A BI <80 is an independent predictor of failure in fast track TAVI.

Advances in transcatheter aortic valve replacement

Evidence in transcatheter aortic valve replacement (TAVR) has accumulated rapidly over the last few years and its application to clinical decision making are becoming more important. In this review, we discuss the advances in TAVR for patient selection, expanding indications, complications, and emerging technologies.

Delirium After Transcatheter Aortic Valve Implantation Under General Anesthesia: Incidence, Predictors, and Relation to Long-Term Survival

BACKGROUND/OBJECTIVES

Prospectively collected data on postoperative delirium (POD) after transcatheter aortic valve implantation (TAVI) are scarce. The aim of this study was to report the incidence and risk factors of delirium after TAVI under general anesthesia and to assess the association of POD with clinical outcome and short‐ and long‐term survival.

DESIGN

Prospective cohort study.

SETTING

Academic medical center.

PARTICIPANTS

A total of 703 subsequent patients undergoing TAVI under general anesthesia between 2008 and 2017.

MEASUREMENTS

Delirium was assessed according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM‐IV), criteria. Outcomes were postprocedural clinical outcome and short‐ and long‐term survival (30 days and 5 years, respectively).

RESULTS

POD was observed in 16.5% (116/703), was the strongest independent predictor of long‐term mortality (hazard ratio = 1.91; 95% confidence interval [CI] = 1.36‐2.70), and was associated with impaired 30‐day and 5‐year survival (92.2% vs 96.8% [P = .025] and 40.0% vs 50.0% [P = .007], respectively). Stroke and new onset of atrial fibrillation were more often observed in delirious patients (6.9% vs 1.9% and 12.1% vs 5.1%, respectively). Strongest independent predictors of POD were prior delirium (odds ratio [OR] = 2.56; 95% CI = 1.52‐4.31) and aortic valve area less than 0.75 cm² (OR = 2.39; 95% CI = 1.53‐3.74).

CONCLUSION

One in six patients experienced POD after TAVI under general anesthesia. POD was the strongest predictor of long‐term mortality and was associated with impaired short‐ and long‐term survival. Prior delirium and a more calcified aortic valve were the strongest independent predictors of POD. J Am Geriatr Soc 67:2325–2330, 2019

Delirium Incidence and Functional Outcomes After Transcatheter and Surgical Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) may be associated with less delirium and allow faster recovery than surgical aortic valve replacement (SAVR).

OBJECTIVE

To examine the association of delirium and its severity with clinical and functional outcomes after SAVR and TAVR.

DESIGN

Prospective cohort study.

SETTING

An academic medical center.

PARTICIPANTS

A total of 187 patients, aged 70 years and older, undergoing SAVR (N = 77) and TAVR (N = 110) in 2014 to 2016.

MEASUREMENTS

Delirium was assessed daily using the Confusion Assessment Method (CAM), with severity measured by the CAM-Severity (CAM-S) score (range = 0-19). Outcomes were prolonged hospitalization (9 days or more); institutional discharge; and functional status, measured by ability to perform 22 daily activities and physical tasks over 12 months.

RESULTS

SAVR patients had a higher incidence of delirium than TAVR patients (50.7% vs 25.5%; P < .001), despite younger mean age (77.9 vs 83.7 years) and higher baseline Mini-Mental State Examination score (26.9 vs 24.7). SAVR patients with delirium had a shorter duration (2.2 vs 3.4 days; P = .04) with a lower mean CAM-S score (4.5 vs 5.7; P = .01) than TAVR patients with delirium. The risk of prolonged hospitalization in no, mild, and severe delirium was 18.4%, 30.8%, and 61.5% after SAVR (P for trend = .009) and 26.8%, 38.5%, and 73.3% after TAVR (P for trend = .001), respectively. The risk of institutional discharge was 42.1%, 58.3%, and 84.6% after SAVR (P for trend = .01) and 32.5%, 69.2%, and 80.0% after TAVR (P for trend <.001), respectively. Severe delirium was associated with delayed functional recovery after SAVR and persistent functional impairment after TAVR at 12 months.

CONCLUSION

Less invasive TAVR was associated with lower incidence of delirium than SAVR. Once delirium developed, TAVR patients had more severe delirium and worse functional status trajectory than SAVR patients did.

REGISTRATION

NCT01845207.

Postoperative Delirium in Individuals Undergoing Transcatheter Aortic Valve Replacement: A Systematic Review and Meta-Analysis

OBJECTIVES

To evaluate the incidence of in-hospital postoperative delirium (IHPOD) after transcatheter aortic valve replacement (TAVR).

DESIGN

Systematic review and meta-analysis.

SETTING

Elective procedures PARTICIPANTS: Individuals undergoing TAVR.

MEASUREMENTS

A literature search was conducted in PubMed, Embase, BioMedCentral, Google Scholar, and the Cochrane Central Register of Controlled Trials (up to December 2017). All observational studies reporting the incidence of IHPOD after TAVR (sample size > 25) were included in our meta-analysis. The reported incidence rates were weighted to obtain a pooled estimate rate with 95% confidence interval (CI).

RESULTS

Of 96 potentially relevant articles, 31 with a total of 32,389 individuals who underwent TAVR were included in the meta-analysis. The crude incidence of IHPOD after TAVR ranged from 0% to 44.6% in included studies, with a pooled estimate rate of 8.1% (95% CI=6.7-9.4%); heterogeneity was high (Q = 449; I = 93%; p_{heterogeneity}  < .001). The pooled estimate rate of IHPOD was 7.2% (95% CI=5.4-9.1%) after transfemoral (TF) TAVR and 21.4% (95% CI=10.3-32.5%) after non-TF TAVR.

CONCLUSION

Delirium occurs frequently after TAVR and is more common after non-TF than TF procedures. Recommendations are made with the aim of standardizing future research to reduce heterogeneity between studies on this important healthcare problem. J Am Geriatr Soc 66:2417-2424, 2018.

Frailty and Delirium in Older Adults: A Systematic Review and Meta-Analysis of the Literature

OBJECTIVES

To evaluate the relationship between frailty and delirium.

DESIGN

Systematic review and meta-analysis.

SETTING

MEDLINE, EMBASE, PubMed, Scopus, Web of Science, and Google Scholar databases were searched for articles on frailty and delirium published on or before October 31, 2017.

PARTICIPANTS

Individuals aged 65 and older.

MEASUREMENTS

Two authors independently reviewed all English-language citations, extracted relevant data, and assessed studies for potential bias. Articles involving pediatric or neurosurgical populations, alcohol or substance abuse, psychiatric illness, head trauma, or stroke, as well as review articles, letters, and case reports were excluded. Studies underwent qualitative or quantitative analysis according to specified criteria. Using a random-effects or fixed-effects model, relative risk (RR) was calculated for the effect of frailty as a predictor of subsequent delirium. Heterogeneity was tested using Q and I² statistics.

RESULTS

We identified 1,626 articles from our initial search, of which 20 fulfilled the selection criteria (N=5,541 participants, mean age 77.8). Eight studies were eligible for meta-analysis, showing a significant association between Q2 frailty and subsequent delirium (RR = 2.19, 95% confidence interval = 1.65-2.91). There was low variability among studies in the measures of association between frailty and delirium (I² 2.24, p-value Q-statistic = .41) but high heterogeneity in the methods used to assess the two conditions.

CONCLUSION

This systematic review and meta-analysis supports the existence of an independent relationship between frailty and delirium, although there is notable methodological heterogeneity between the methods used to assess the 2 conditions. Future studies are needed to better delineate the dynamics between these syndromes.

Frailty and Exercise Training: How to Provide Best Care after Cardiac Surgery or Intervention for Elder Patients with Valvular Heart Disease

The aim of this literature review was to evaluate existing evidence on exercise-based cardiac rehabilitation (CR) as a treatment option for elderly frail patients with valvular heart disease (VHD). Pubmed database was searched for articles between 1980 and January 2018. From 2623 articles screened, 61 on frailty and VHD and 12 on exercise-based training for patients with VHD were included in the analysis. We studied and described frailty assessment in this patient population. Studies reporting results of exercise training in patients after surgical/interventional VHD treatment were analyzed regarding contents and outcomes. The tools for frailty assessment included fried phenotype frailty index and its modifications, multidimensional geriatric assessment, clinical frailty scale, 5-meter walking test, serum albumin levels, and Katz index of activities of daily living. Frailty assessment in CR settings should be based on functional, objective tests and should have similar components as tools for risk assessment (mobility, muscle mass and strength, independence in daily living, cognitive functions, nutrition, and anxiety and depression evaluation). Participating in comprehensive exercise-based CR could improve short- and long-term outcomes (better quality of life, physical and functional capacity) in frail VHD patients. Such CR program should be led by cardiologist, and its content should include (1) exercise training (endurance and strength training to improve muscle mass, strength, balance, and coordination), (2) nutrition counseling, (3) occupational therapy (to improve independency and cognitive function), (4) psychological counseling to ensure psychosocial health, and (5) social worker counseling (to improve independency). Comprehensive CR could help to prevent, restore, and reduce the severity of frailty as well as to improve outcomes for frail VHD patients after surgery or intervention.