Global prevalence and predictors of postoperative delirium among non-cardiac surgical patients: A systematic review and meta-analysis

Mortality Risk Following Delirium in Older Inpatients: A Systematic Review and Meta-Analysis

BACKGROUND

The onset of delirium in older inpatients is associated with worse outcomes, including longer length of hospital stay, loss of functionality, loss of cognitive function, sleep disorders, increased polypharmacy, higher rates of adverse effects, and mortality. Previous studies have analyzed mortality after delirium, but without discriminating between settings, time, or critical conditions.

AIMS

To assess the pooled incidence of delirium and risk of mortality at different times after hospital admission in older people and its association with mortality and length of stay in hospitalized people aged 65 years or older.

METHODS

This systematic review and meta-analysis included studies analyzing the incidence of delirium and mortality. MEDLINE, Scopus, and the Web of Science were searched from inception to December 2023. PRISMA guidelines were followed. Inclusion criteria were original peer-reviewed studies in medical hospital areas using validated screening or diagnostic methods and quantifying mortality at admission or after excluding surgical patients. Exclusion criteria were studies that included only participants with a single condition at baseline, such as cancer, pneumonia, or frailty, or who were admitted to a specific unit such as the intensive care unit, as well as studies that assessed delirium in surgical areas. Study quality was assessed with Joanna Briggs Institute Critical Appraisal tools. The statistical analysis was performed in RevMan v5.4.0 (Cochrane Collaboration, Oxford, UK), using a random-effects model to calculate incidence, mortality, and length of hospital stay along with their 95% confidence intervals (CIs). The PROSPERO registration number for the review was CRD42023491604.

RESULTS

In the 32 included studies, the pooled cumulative incidence of delirium was 28.79% (95% confidence interval [CI] 24.06%, 33.51%). The mortality risk was higher in patients who had delirium during admission (odds ratio [OR] 5.23, 95% CI [3.45, 7.93]). This varied by time point: 1 month, OR 3.80 (95% CI 2.40, 6.00); 6 months, OR 3.48 (95% CI [2.01, 6.01]); 12 months, OR 2.73 (95% CI [2.07, 3.60]); 2 years, OR 2.09 (95% CI [1.57, 2.78]); and 5 years, OR 3.34 (95% CI [2.40, 4.64]). In the pooled analysis, mean length of hospital stay was 2.26 days (95% CI [0.54, 3.99]) longer in patients with delirium.

LINKING EVIDENCE TO ACTION

This study shows the markedly increased risk of mortality in older people with delirium during hospital admission and over the first month, in addition to an increased length of stay. The onset of delirium leads to increased use of healthcare resources. These data help to quantify the impact that delirium has on the health of older people, with implications for health system management. The evidence highlights the need to implement preventive pharmacological treatment or multicomponent strategies that minimize the onset of delirium in the older population.

TRIAL REGISTRATION

The PROSPERO registration number for the review was: CRD42023491604, available at: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=491604.

Artificial intelligence and the impact of multiomics on the reporting of case reports

The integration of artificial intelligence (AI) and multiomics has transformed clinical and life sciences, enabling precision medicine and redefining disease understanding. Scientific publications grew significantly from 2.1 million in 2012 to 3.3 million in 2022, with AI research tripling during this period. Multiomics fields, including genomics and proteomics, also advanced, exemplified by the Human Proteome Project achieving a 90% complete blueprint by 2021. This growth highlights opportunities and challenges in integrating AI and multiomics into clinical reporting. A review of studies and case reports was conducted to evaluate AI and multiomics integration. Key areas analyzed included diagnostic accuracy, predictive modeling, and personalized treatment approaches driven by AI tools. Case examples were studied to assess impacts on clinical decision-making. AI and multiomics enhanced data integration, predictive insights, and treatment personalization. Fields like radiomics, genomics, and proteomics improved diagnostics and guided therapy. For instance, the "AI radiomics, genomics, oncopathomics, and surgomics project" combined radiomics and genomics for surgical decision-making, enabling preoperative, intraoperative, and postoperative interventions. AI applications in case reports predicted conditions like postoperative delirium and monitored cancer progression using genomic and imaging data. AI and multiomics enable standardized data analysis, dynamic updates, and predictive modeling in case reports. Traditional reports often lack objectivity, but AI enhances reproducibility and decision-making by processing large datasets. Challenges include data standardization, biases, and ethical concerns. Overcoming these barriers is vital for optimizing AI applications and advancing personalized medicine. AI and multiomics integration is revolutionizing clinical research and practice. Standardizing data reporting and addressing challenges in ethics and data quality will unlock their full potential. Emphasizing collaboration and transparency is essential for leveraging these tools to improve patient care and scientific communication.

Perioperative Risk Factors for Postoperative Delirium in Non-dementia Older Patients after Non-cardiac Surgery and Anesthesia: A Prospective Study

BACKGROUND

To investigate the incidence and perioperative risk factors for postoperative delirium (POD) in non-dementia older patients who underwent anesthesia for non-cardiac surgery.

METHODS

This prospective cohort study was conducted on 195 non-dementia older patients, aged 60 years or older, who were hospitalized after non-cardiac surgery and anesthesia. The Confusion Assessment Method for the Intensive Care Unit was used to evaluate the occurrence of POD. Incidence of POD was reported. We conducted univariate and multivariate logistic regression to identify the risk factors associated with POD.

RESULTS

A total of 195 patients were enrolled; 172 completed the study. POD occurred in seven patients within three days after anesthesia, which is a 4.1% incidence of POD. Multivariate logistic analysis showed arrhythmia, coagulopathy, urinary comorbidity, minimum intraoperative heart rate, and minimum post-anesthesia care unit (PACU) pain score as independent risk factors for POD. A minimum PACU pain score >1 is the optimum cutoff pain score for developing POD, with a sensitivity of 85.7% and a specificity of 69.1%. The postoperative complication rate and in-hospital mortality were significantly higher for patients with POD compared to those without POD.

CONCLUSION

The incidence of POD in the study population is 4.1%. Arrhythmia, coagulopathy, urinary comorbidity, minimum intraoperative heart rate, and minimum PACU pain score were independent risk factors for POD. The minimum PACU pain score is the strongest independent risk factor of POD. POD is associated with increased postoperative complications and in-hospital mortality rates in non-dementia older patients.

Risk factors of delirium after cardiac surgery: a systematic review and meta-analysis

BACKGROUND

Post-operative delirium (POD) is a relatively common occurrence following surgical procedures, particularly cardiac surgeries. Given that the majority of pharmacologic treatments for delirium have demonstrated inadequate efficacy, it is of great importance to identify risk factors to prevent delirium or reduce its complications. Consequently, in this systematic review and meta-analysis, we identified risk factors of POD after cardiac surgery.

METHOD

A comprehensive search of the literature was conducted using the databases Scopus, PubMed, and Web of Science from the inception to April 22, 2024. The objective was to identify prospective cohorts that had assessed the risk factors associated with POD in patients undergoing cardiac surgery using multivariate regression.

RESULTS

Of the 3,166 studies that were initially screened, 23 were included in the review. Nine risk factors were evaluated including age (OR 1.06, 95% CI (1.04, 1.08), p < 0.001), pre-operative depression (OR 3.71, 95% CI (2.45, 5.62), p < 0.001), post-operative atrial fibrillation (AF) (OR 2.39, 95% CI (1.79, 3.21), p < 0.001), hypertension (HTN) (OR 1.64, 95% CI (0.75, 3.56), p = 0.212), age ≥ 65 (OR 3.32, 95% CI (2.40, 4.60), p < 0.001), pre-operative AF (OR 4.43, 95% CI (2.56, 7.69), p < 0.001), diabetes mellitus (OR 2.16, 95% CI (1.39, 3.35), p = 0.001), combined coronary artery bypass graft (CABG) + valve surgery (OR 2.73, 95% CI (1.66, 4.49), p < 0.001), and cardiopulmonary bypass (CPB) time (OR 1.02, 95% CI (1.01, 1.04), p = 0.001).

CONCLUSIONS

A total of nine risk factors were evaluated, from which eight were found to have a statistically significant effect on the risk of developing POD. These factors can be employed to more effectively identify at-risk patients and to prevent the occurrence of POD. Furthermore, this approach can facilitate earlier diagnosis and more effective patient care.

Retrospective comparison of the effects of remimazolam and dexmedetomidine on postoperative delirium in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia

PURPOSE

Remimazolam is often used for perioperative sedation due to its rapid onset and offset. However, the possible association between remimazolam and postoperative delirium (POD) remains undetermined. The present study evaluated whether remimazolam increased the incidence of POD compared with dexmedetomidine in elderly patients undergoing orthopedic surgery of the lower extremities.

METHODS

This retrospective study included patients aged ≥ 65 years who had undergone orthopedic surgery of the lower extremities under spinal anesthesia from January 2020 to November 2022 and were sedated with continuous intravenous infusion of dexmedetomidine or remimazolam. The incidence of POD was assessed through a validated comprehensive review process of each patient's medical records. The effect of remimazolam on the occurrence of POD compared with dexmedetomidine was evaluated by propensity score weighted multivariable logistic models.

RESULTS

A total of 447 patients were included in the final analysis. The crude incidence of POD within 3 days after surgery was 7.5% (17/226) in the dexmedetomidine group and 11.8% (26/221) in the remimazolam group, increasing to 9.7% (22/226) and 15.8% (35/221), respectively (p = 0.073), within 5 days. The multivariable models showed that, compared with dexmedetomidine, intraoperative sedation with remimazolam significantly increased the occurrence of POD within 3 days (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.31 to 3.82, p = 0.003) and 5 days (OR 2.10, 95% CI 1.32 to 3.40, p = 0.002).

CONCLUSION

Compared with dexmedetomidine, remimazolam infusion may be associated with a higher risk of POD in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia.

The Role of Neutrophil-to-Lymphocyte Ratio (NLR) in Urosepsis-Associated Delirium

Introduction Urosepsis is a systemic, dysregulated, inflammatory reaction to a urinary tract infection and can have severe effects on all systems, which can often lead to multi-organ failure and death. Sepsis-associated delirium is a common complication in critically ill patients, contributing to adverse outcomes and prolonged hospital stays. The neutrophil-to-lymphocyte ratio (NLR) has emerged as a potential biomarker for sepsis severity and prognosis. Material and methods Our study investigates the utility of NLR in the diagnostic strategies for urosepsis-associated delirium in a cohort of 76 patients with sepsis and septic shock admitted to the Intensive Care Unit (ICU). We performed a single-centre retrospective observational study in the Craiova Clinical Emergency Hospital between June and October 2023. Results Patients with urological conditions that were diagnosed with urosepsis included 76 patients. These patients were clustered as follows: a group with delirium (37 patients, 48.7%) and another group without delirium (39 patients, 51.3%). Complete blood count parameters were obtained upon admission, and delirium was assessed using standardized diagnostic criteria. We identified a strong significant positive correlation between elevated NLR values on ICU admission and the development of delirium during hospitalization in urosepsis patients. Receiver operating characteristic (ROC) analysis showed similar diagnostic performance for NLR score. Conclusions The findings suggest that NLR may serve as a valuable biomarker for early detection, risk stratification, and guiding therapeutic interventions in urosepsis-associated delirium, thus improving outcomes in critically ill patients.

Development and Validation of a Prognostic Classification Model Predicting Postoperative Adverse Outcomes in Older Surgical Patients Using a Machine Learning Algorithm: Retrospective Observational Network Study

BACKGROUND

Older adults are at an increased risk of postoperative morbidity. Numerous risk stratification tools exist, but effort and manpower are required.

OBJECTIVE

This study aimed to develop a predictive model of postoperative adverse outcomes in older patients following general surgery with an open-source, patient-level prediction from the Observational Health Data Sciences and Informatics for internal and external validation.

METHODS

We used the Observational Medical Outcomes Partnership common data model and machine learning algorithms. The primary outcome was a composite of 90-day postoperative all-cause mortality and emergency department visits. Secondary outcomes were postoperative delirium, prolonged postoperative stay (≥75th percentile), and prolonged hospital stay (≥21 days). An 80% versus 20% split of the data from the Seoul National University Bundang Hospital (SNUBH) and Seoul National University Hospital (SNUH) common data model was used for model training and testing versus external validation. Model performance was evaluated using the area under the receiver operating characteristic curve (AUC) with a 95% CI.

RESULTS

Data from 27,197 (SNUBH) and 32,857 (SNUH) patients were analyzed. Compared to the random forest, Adaboost, and decision tree models, the least absolute shrinkage and selection operator logistic regression model showed good internal discriminative accuracy (internal AUC 0.723, 95% CI 0.701-0.744) and transportability (external AUC 0.703, 95% CI 0.692-0.714) for the primary outcome. The model also possessed good internal and external AUCs for postoperative delirium (internal AUC 0.754, 95% CI 0.713-0.794; external AUC 0.750, 95% CI 0.727-0.772), prolonged postoperative stay (internal AUC 0.813, 95% CI 0.800-0.825; external AUC 0.747, 95% CI 0.741-0.753), and prolonged hospital stay (internal AUC 0.770, 95% CI 0.749-0.792; external AUC 0.707, 95% CI 0.696-0.718). Compared with age or the Charlson comorbidity index, the model showed better prediction performance.

CONCLUSIONS

The derived model shall assist clinicians and patients in understanding the individualized risks and benefits of surgery.

Delirium and sleep disturbances-A narrative review

BACKGROUND

Delirium is considered a severe complication. It increases morbidity and mortality and represents a major financial burden for healthcare systems. Thus, prevention becomes a focal point of research. Sleep disturbances have been linked to the occurrence of delirium. Consequently, several interventions that target a possible connection have been studied in recent years.

OBJECTIVE

This narrative literature review explores the published data for an association between delirium and different types of sleep disturbances, the pathophysiological interactions and prevention methods.

MATERIAL AND METHODS

A literature search was carried out utilizing PubMed, the Cochrane Library, Livivo and Google Scholar.

RESULTS

Although an association between several types of sleep disturbances and delirium has been shown, no causality has been proven so far. Nevertheless, several pharmacological and nonpharmacological interventions for delirium prevention have been attempted; however, the level of evidence is insufficient at this point.

CONCLUSION

Further research is required to prove causality between sleep disturbances and delirium. Nonpharmacological interventions should be used in construction and maintenance of intensive care units and hospitals. Pharmacological interventions could be effective for prevention but further research is needed. Screening patients at risk of delirium for sleep disturbances and antihistaminergic/anticholinergic medication seems beneficial.

Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis

STUDY OBJECTIVE

To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients.

DESIGN

A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022.

SETTING

Postoperative assessments.

PATIENTS

Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded.

MEASUREMENTS

Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI.

MAIN RESULTS

Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00).

CONCLUSIONS

Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.

Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis

Importance

Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed.

Objective

To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery.

Data Sources

MEDLINE, EMBASE, and CINAHL from inception to May 2020.

Study Selection

Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020.

Data Extraction and Synthesis

Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data.

Main Outcomes and Measures

The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD.

Results

A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72).

Conclusions and Relevance

In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.

Investigation on Awareness of Cognitive Impairment Diseases Among Surgical Practitioners

Objective

In this study, we assessed the awareness of cognitive dysfunction and the reasons for the lack of awareness among surgical practitioners in Jiaxing.

Methods

Questionnaires were distributed to surgical practitioners covering all Class III and Class II hospitals in Jiaxing. Respondents were asked to make selections regarding the demographic data, clinical attitudes and practices of cognitive dysfunction based on Alzheimer's Disease Assessment Scale (ADKS) of the Chinese version.

Results

A total of 180 questionnaires were distributed, 12 of which were incomplete, with 168 being included for analysis. The respondents were generally under 50 years of age (150, 89.3%), predominantly males (146, 86.9%), and surgeons (153, 91.1%). They generally had a bachelor's or master's degrees (165, 98.2%), and served in Class III hospitals (127, 75.6%). The title of the practitioner was found to impact their attention toward their patients' cognitive status during preoperative preparation (P<0.05). Titles and hospital levels were found to influence decisions of surgical practitioners to invite specialist physicians for consultation and assessment when a patient was identified to have cognitive dysfunction (P<0.05). Most surgical practitioners had little knowledge or training about Alzheimer's disease and cognitive dysfunction. Among the 168 respondents, the mean ADKS score was 20.14±2.40, and the awareness rate was 67.1%, indicating that the surgical practitioner's title influenced ADKS score (P<0.001).

Conclusion

Surgical practitioners, especially young physicians and those in Class II hospitals, had lower awareness of cognitive dysfunction, with low ADKS scores; therefore, they needed to be further trained to recognize cognitive dysfunction.

Lipopolysaccharide-Induced Delirium-like Behaviour in a Rat Model of Chronic Cerebral Hypoperfusion Is Associated with Increased Indoleamine 2,3-Dioxygenase Expression and Endotoxin Tolerance

Indoleamine 2,3-dioxygenase (IDO) and the tryptophan-kynurenine pathway (TRP-KP) are upregulated in ageing and could be implicated in the pathogenesis of delirium. This study evaluated the role of IDO/KP in lipopolysaccharide (LPS)-induced delirium in an animal model of chronic cerebral hypoperfusion (CCH), a proposed model for delirium. CCH was induced by a permanent bilateral common carotid artery ligation (BCCAL) in Sprague Dawley rats to trigger chronic neuroinflammation-induced neurodegeneration. Eight weeks after permanent BCCAL, the rats were treated with a single systemic LPS. The rats were divided into three groups: (1) post-BCCAL rats treated with intraperitoneal (i.p.) saline, (2) post-BCCAL rats treated with i.p. LPS 100 μg/kg, and (3) sham-operated rats treated with i.p. LPS 100 μg/kg. Each group consisted of 10 male rats. To elucidate the LPS-induced delirium-like behaviour, natural and learned behaviour changes were assessed by a buried food test (BFT), open field test (OFT), and Y-maze test at 0, 24-, 48-, and 72 h after LPS treatment. Serum was collected after each session of behavioural assessment. The rats were euthanised after the last serum collection, and the hippocampi and cerebral cortex were collected. The TRP-KP neuroactive metabolites were measured in both serum and brain tissues using ELISA. Our data show that LPS treatment in CCH rats was associated with acute, transient, and fluctuated deficits in natural and learned behaviour, consistent with features of delirium. These behaviour deficits were mild compared to the sham-operated rats, which exhibited robust behaviour impairments. Additionally, heightened hippocampal IDO expression in the LPS-treated CCH rats was associated with reduced serum KP activity together with a decrease in the hippocampal quinolinic acid (QA) expression compared to the sham-operated rats, suggested for the presence of endotoxin tolerance through the immunomodulatory activity of IDO in the brain. These data provide new insight into the underlying mechanisms of delirium, and future studies should further explore the role of IDO modulation and its therapeutic potential in delirium.

Parental Education and Delirium Risk after Surgery in Older Adults

OBJECTIVES

Efforts to conceptualize risk factors for postoperative delirium in older adults have focused on the time proximate to the episode, but how early-life exposures influence delirium risk is poorly understood.

METHODS

An observational cohort of 547 patients aged 70+undergoing major non-cardiac surgery at two academic medical centers in Boston. Demographic characteristics, cognition, parental education, health, and participation in cognitively stimulating activities were assessed prior to surgery. Delirium incidence and severity were measured daily during hospitalization.

RESULTS

Higher paternal education was associated with significantly lower incidence of delirium (X2(1, N =547)=8.35, p <.001; odds ratio OR=.93, 95% CI, .87 to .98) and inversely associated with delirium severity (r(545)=-.13, p <.001). Higher maternal education was associated with lower delirium incidence but did not reach statistical significance. The effect of paternal education on delirium incidence was independent of the patient's education, estimated premorbid intelligence, medical comorbidities, neighborhood disadvantage, and participation in cognitively stimulating activities (X2(2, N =547)=31.22, p <.001).

CONCLUSIONS

Examining early-life exposures may yield unique insights into the risks and pathogenesis of delirium.

CLINICAL IMPLICATIONS

Evaluating long-term factors that increase vulnerability to delirium may improve our ability to calculate risk. It may guide clinical decision-making and inform pre- and post-operative recommendations.

Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial

Background

Patients who develop postoperative delirium (POD) have several clinical complications, such as increased morbidity, increased hospital stays, higher hospital costs, cognitive and functional impairment, and higher mortality. POD is a clinical condition preventable by standard non-pharmacological measures An intensive Occupational Therapy (OT) intervention has been shown to be highly effective in preventing delirium in critically ill medical patients, but it is unknown the effect in surgical patients. Thus, we designed a prospective clinical study with the aim to determine whether patients undergoing intervention by the OT team have a lower incidence of POD compared to the group treated only with standard measures.

Methods

A multicenter, single-blind, randomized clinical trial was conducted between October 2018 and April 2021, in Santiago of Chile, at a university hospital and at a public hospital. Patients older than 75 years undergoing elective major surgery were eligible for the trial inclusion. Patients with cognitive impairment, severe communication disorder and cultural language limitation, delirium at admission or before surgery, and enrolled in another study were excluded. The intervention consisted of OT therapy twice a day plus standard internationally recommended non-pharmacological prevention intervention during 5 days after surgery. Our primary outcome was development of delirium and postoperative subsyndromal delirium.

Results

In total 160 patients were studied. In the interventional group, treated with an intensive prevention by OT, nine patients (12.9%) developed delirium after surgery and in the control group four patients (5.5%) [p = 0.125, RR 2.34 CI 95 (0.75-7.27)]. Whereas subsyndromal POD was present in 38 patients in the control group (52.1%) and in 34 (48.6%) in the intervention group [p = 0.4, RR 0.93 CI95 (0.67-1.29)]. A post hoc analysis determined that the patient's comorbidity and cognitive status prior to hospitalization were the main risk factors to develop delirium after surgery.

Discussion

Patients undergoing intervention by the OT team did not have a lower incidence of POD compared to the group treated only with standard non-pharmacological measures in adults older than 75 years who went for major surgery.

Clinical trial registration

www.ClinicalTrials.gov, identifier NCT03704090.

Evidence-Based Guideline on Management of Postoperative Delirium in Older People for Low Resource Setting: Systematic Review Article

Background

Postoperative delirium is the highest prevalence and life-threatening complication following geriatric surgery. The overall incidence rate varies from 5% to 52% of hospitalized surgical patients based on the type of surgery that often began in the postanesthesia care unit and continues up to 5 days post-surgery. Postoperative delirium manifests as a hypoactive, hyperactive and mixed subtype. The mechanism of delirium development is not clear, but it is accepted that delirium is a result of the patient's underlying vulnerabilities or risk factors combined with an outside stressor such as infection or surgery.

Objective

To develop evidence-based recommendations for the prevention, diagnosis, and treatment of postoperative delirium.

Methods

Literature was searched from PubMed, CINAH, Google Scholar, and Cochrane databases that are published from 2010 to 2021 by formulating inclusion and exclusion criteria. Filtering was made depending on methodological quality, outcome, and data on population. Finally, 11 meta-analysis, 11 systematic reviews, 7 interventional studies, 11 observational studies, and recommendations of the previous clinical practice guideline developed by the American and European are included in this review.

Results

A total of 43 studies were considered in this evaluation. The development of this guideline was based on nine studies on risk stratification for postoperative delirium, eighteen studies on risk minimization and prevention for postoperative delirium, five studies on diagnosis for postoperative delirium, and eleven studies on treatments for postoperative delirium.

Conclusion

Postoperative delirium management can be categorized into risk assessment, risk minimization, early diagnosis, and treatment. Early diagnosis is critical to trigger focused and effective treatment. Non-pharmacological interventions are the first-line management for both hypoactive and hyperactive postoperative with considering contributory factors and underlying causes. Antipsychotics should only be used for hyperactive delirium individuals who try to harm themselves. Current evidence suggested that dexmedetomidine can be used as a treatment option for postoperative delirium.

Postoperative cognitive dysfunction in older surgical patients associated with increased healthcare utilization: a prospective study from an upper-middle-income country

BACKGROUND

Perioperative neurocognitive disorder includes postoperative cognitive dysfunction (POCD) and postoperative delirium (POD). Concerning inconclusive consequences of POCD compared with POD, we explored the association between either POCD or POD and functional decline as well as healthcare utilization.

METHODS

Patients aged at least 60 years who underwent a major operation were enrolled. POCD was defined as a decrease in the Montreal Cognitive Assessment (MoCA) score (≥ 2) 1 week after surgery. Postoperative delirium (POD) was defined according to the criteria of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The primary outcome was instrumental activities of daily living (IADLs) 3 months after discharge. Secondary outcomes were the length of stay (LOS), hospital cost, and factors that affected functional decline 3 months after surgery. The multivariate model, including potential confounding factors, namely age, gender, surgery type, and postoperative complications, was used to analyze possible factors that influenced a reduction in function, and the results were expressed by using adjusted relative risk (RR) and 95%CI.

RESULTS

Two hundred eighty-nine patients with a mean age of 72 years were enrolled. The incidence of POCD at 1 week was 28.5%. At their 3-month follow-ups, the patients with POCD were not associated with IADL decline. Nevertheless, patients with POCD were more likely to need a prolonged LOS (11 days [1, 46] vs. 8 days [2, 42]; P = 0.01), and incur higher hospital costs (8973.43 USD [3481.69, 11 763.74] vs. 5913.62 USD [332.43, 19 567.33]; P < 0.001). Additionally, the patients experiencing POD demonstrated increased risks of reducing their IADLs (adjusted RR 2.33; 95% CI, 1.15-4.71; P = 0.02).

CONCLUSIONS

POCD at 1 week leaded to increase healthcare utilization in a middle-income country. POD during hospitalization was associated with a decline in function after surgery and increased health care utilization.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20190115001 .

Melatonin for prevention of postoperative delirium after lower limb fracture surgery in elderly patients (DELIRLESS): study protocol for a multicentre randomised controlled trial

INTRODUCTION

Postoperative delirium (POD) is one of the most frequent complication after surgery in elderly patients, and is associated with increased morbidity and mortality, prolonged length of stay, cognitive and functional decline leading to loss of autonomy, and important additional healthcare costs. Perioperative inflammatory stress is a key element in POD genesis. Melatonin exhibits antioxidative and immune-modulatory proprieties that are promising concerning delirium prevention, but in perioperative context literature are scarce and conflicting. We hypothesise that perioperative melatonin can reduce the incidence of POD.

METHODS AND ANALYSIS

The DELIRLESS trial is a prospective, national multicentric, phase III, superiority, comparative randomised (1:1) double-blind clinical trial. Among patients aged 70 or older, hospitalised and scheduled for surgery of a severe fracture of a lower limb, 718 will be randomly allocated to receive either melatonin 4 mg per os or placebo, every night from anaesthesiologist preoperative consultation and up to 5 days after surgery. The primary outcome is POD incidence measured by either the French validated translation of the Confusion Assessment Method (CAM) score for patients hospitalised in surgery, or CAM-ICU score for patients hospitalised in ICU (Intensive Care Unit). Daily delirium assessment will take place during 10 days after surgery, or until the end of hospital stay if it is shorter. POD cumulative incidence function will be compared at day 10 between the two randomised arms in a competing risks framework, using the Fine and Grey model with death as a competing risk of delirium.

ETHICS AND DISSEMINATION

The DELIRLESS trial has been approved by an independent ethics committee the Comité de Protection des Personnes (CPP) Sud-Est (ref CPP2020-18-99 2019-003210-14) for all study centres. Participant recruitment begins in December 2020. Results will be published in international peer-reviewed medical journals.

TRIAL REGISTRATION NUMBER

NCT04335968, first posted 7 April 2020.

PROTOCOL VERSION IDENTIFIER

N°3-0, 3 May 2021.