Brief report: preoperative frailty in older surgical patients is associated with early postoperative delirium

Unraveling the impact of frailty on postoperative delirium in elderly surgical patients: a systematic review and meta-analysis

BACKGROUND

Frailty has been consistently implicated as a pivotal factor in the onset of delirium following anesthesia and surgery. Nonetheless, a comprehensive understanding of the relationship between frailty and delirium remains to be elucidated. This study addresses that knowledge gap.

METHODS

A comprehensive search of literature databases identified 43 relevant studies involving 14,441 participants. The studies were subjected to a rigorous quality assessment using the Newcastle-Ottawa Scale. Statistical analysis was conducted using Review Manager (v5.4.1), including subgroup and sensitivity analyses.

RESULTS

Meta-analysis revealed a significant association between preoperative physical frailty and postoperative delirium (pooled odds ratio: 2.47; 95% confidence interval: 2.04-2.99; I2 = 46.7%). The baseline frailty rate was 34.0% (4,910/14,441), while the overall incidence of postoperative delirium was 20% (2,783/14,441). Subgroup analyses based on characteristics such as race, frailty-assessment tools, and surgical types were conducted to explore potential sources of heterogeneity. This meta-analysis provided compelling evidence supporting a notable link between preoperative physical frailty and an increased risk of postoperative delirium in older surgical patients. Early identification through frailty screening can enable targeted interventions, potentially enhancing overall management and individualized treatment. Integrating frailty assessment into preoperative evaluation may improve predictive accuracy in surgical planning and anesthesia management.

CONCLUSIONS

Future research could focus on optimizing the integration of frailty assessment into preoperative protocols for timely intervention and improved patient outcomes.

TRIAL REGISTRATION

The review protocol was registered with PROSPERO (CRD42023390486), date of registration: Aug 11, 2023.

Incidence and risk factors of postoperative delirium in elderly surgical patients 2023

Postoperative delirium has the potential to impact individuals of all age groups, with a significant emphasis on the elderly population. Its presence leads to an increase in surgical morbidity and mortality rates, as well as a notable prolongation of hospital stays. However, there is a lack of research regarding the prevalence, risk factors, and implications of postoperative delirium in developing nations like Ethiopia, which affects both patients and healthcare institutions. An observational study was conducted at hospitals in the South Gondar Zone to diagnose postoperative delirium in the Post-Anesthesia Care Unit (PACU) using the Nursing Delirium Screening Scale. Both bivariable and multivariable logistic regression techniques were employed to analyze the association between independent factors and postoperative delirium. The strength of the association was indicated by the odds ratio with a 95% confidence interval (CI). Any p-values below 0.05 were considered statistically significant. The incidence of postoperative delirium was determined to be 41%. In the multivariate logistic regression analysis, several factors were identified as significantly associated with postoperative delirium. These factors include an age of 75 or older (AOR, 11.24; 95% CI, 4.74-26.65), ASA-PS IV (AOR, 3.25; 95% CI, 1.81-5.85), severe functional impairment of activities of daily living (AOR, 3.29; 95% CI, 1.06-10.20), premedication with benzodiazepine (AOR, 4.61; 95% CI, 2.48-8.57), intraoperative estimated blood loss exceeding 1000 ml (AOR, 2.74; 95% CI, 1.50-4.98), and intraoperative ketamine use (AOR, 3.84; 95% CI, 2.21-6.68). Additionally, postoperative delirium was found to significantly prolong the duration of stay in the post-anesthesia care unit (PACU) and the length of hospital stay (p-value < 0.05). Patients aged 75 or older, ASA-PS IV, experiencing severe functional impairment of ADL, patients premedicated with benzodiazepine, patients with intraoperative estimated blood loss exceeding 1000 ml, and intraoperative ketamine use were identified as risk factors for post-operative delirium.

Incidence and relative risk of delirium after major surgery for patients with pre-operative depression: a systematic review and meta-analysis

BACKGROUND

Delirium is a common and potentially serious complication after major surgery. A previous history of depression is a known risk factor for experiencing delirium in patients admitted to the hospital, but the generalised risk has not been estimated in surgical patients.

METHODS

We conducted a systematic review and meta-analysis of studies reporting the incidence or relative risk (or relative odds) of delirium in the immediate postoperative period for adults with pre-operative depression. We included studies that defined depression as either a formal pre-existing diagnosis or having clinically important depressive symptoms measured using a patient-reported instrument before surgery. Multilevel random effects meta-analyses were used to estimate the pooled incidences and pooled relative risks. We also conducted subgroup analyses by various study-level characteristics to identify important moderators of pooled estimates.

RESULTS

Forty-two studies (n = 4,664,051) from five continents were included. The pooled incidence of postoperative delirium for patients with pre-operative depression was 29% (95%CI 17-43%, I2 = 99.0%), compared with 15% (95%CI 6-28%, I2 = 99.8%) in patients without pre-operative depression and 21% (95% CI 11-33%, I2 = 99.8%) in the cohorts overall. For patients with pre-operative depression, the risk of delirium was 1.91 times greater (95%CI 1.68-2.17, I2 = 42.0%) compared with patients without pre-operative depression.

CONCLUSIONS

Patients with a previous diagnosis of depression or clinically important depressive symptoms before surgery have substantially greater risk of experiencing delirium after surgery. Clinicians and patients should be informed of these increased risks. Robust screening and other risk mitigation strategies for postoperative delirium are warranted, especially for patients with pre-operative depression.

A Retrospective Study Establishing a Nomogram Predictive Model for Postoperative High-Activity Delirium After Non-Cardiac Surgery

Background

Postoperative high-activity delirium (PDHA) manifests as a high alertness, restlessness, hallucinations, and delusions. Occurrence of PDHA represents an increased risk of poor prognosis for patients.

Objective

To establish and validate a nomogram prediction model for high-activity delirium after non-cardiac surgery in a post-anesthesia care unit (PACU).

Methods

This study retrospectively enrolled adult patients who underwent non-cardiac surgery and were observed in the PACU as training data. Patients were divided into PDHA (199 patients) and non-PDHA (396 patients) groups. Patients' general data, preoperative indicators, intraoperative conditions, and postoperative PACU conditions were collected. The risk factors for PDHA were identified using univariate and multivariate logistic regression analyses. A predictive column chart was created using R language. Adult patients who underwent non-cardiac surgery and entered the PACU for observation were randomly selected as the validation set data (198 cases) for model performance validation.

Results

The incidence rate of adult PDHA in the PACU was 0.275%. Sex, age, smoking history, low preoperative albumin level, Society of Anesthesiologists (ASA) classification, anesthesia duration, and postoperative PACU pain score were independent risk factors for hyperactive delirium in PACU adults. In this study, an adult PACU PDHA nomogram prediction model was developed. The training dataset verified that the ROC curve (area under the curve) and 95% confidence interval (95% CI) were 0.936 (0.917-0.955). The ROC curve of the validation data row showed that the area under the curve and 95% CI were 0.926 (0.885-0.967).

Conclusion

The nomogram predictive model for PACU adult high-activity delirium constructed in this study showed good predictive performance. This model could enable the visualization and graphical prediction of adult high-activity delirium occurrence after PACU, which has clinical value.

Incidence of post-operative delirium increases as severity of frailty increases

OBJECTIVE

The surgical population is ageing and often frail. Frailty increases the risk for poor post-operative outcomes such as delirium, which carries significant morbidity, mortality and cost. Frailty is often measured in a binary manner, limiting pre-operative counselling. The goal of this study was to determine the relationship between categorical frailty severity level and post-operative delirium.

METHODS

We performed an analysis of a retrospective cohort of older adults from 12 January 2018 to 3 January 2020 admitted to a tertiary medical center for elective surgery. All participants underwent frailty screening prior to inpatient elective surgery with at least two post-operative delirium assessments. Planned ICU admissions were excluded. Procedures were risk-stratified by the Operative Stress Score (OSS). Categorical frailty severity level (Not Frail, Mild, Moderate, and Severe Frailty) was measured using the Edmonton Frail Scale. Delirium was determined using the 4 A's Test and Confusion Assessment Method-Intensive Care Unit.

RESULTS

In sum, 324 patients were included. The overall post-operative delirium incidence was 4.6% (15 individuals), which increased significantly as the categorical frailty severity level increased (2% not frail, 6% mild frailty, 23% moderate frailty; P < 0.001) corresponding to increasing odds of delirium (OR 2.57 [0.62, 10.66] mild vs. not frail; OR 12.10 [3.57, 40.99] moderate vs. not frail).

CONCLUSIONS

Incidence of post-operative delirium increases as categorical frailty severity level increases. This suggests that frailty severity should be considered when counselling older adults about their risk for post-operative delirium prior to surgery.

The impact of preoperative frailty on perioperative neurocognitive disorders in elderly patients: A systematic review and meta-analysis

Background

Perioperative neurocognitive disorders (PNDs) were the most common complication in elderly patients undergoing surgery. Early identification of risk factors for PNDs and implementation of preventive measures were critical to improve prognosis. We performed this systematic review and meta-analysis to explore the impact of preoperative frailty on PNDs in elderly surgical patients.

Materials and Methods

Systematic searches were performed in PubMed, Embase, and Web of Science. A fixed-effect model in RevMan5.3 software was conducted due to the low heterogeneity. The potential risk bias was assessed through Funnel plot and Egger's test. Sensitivity analysis was used to examine the robustness of the outcomes.

Results

Sixteen cohort studies enrolling 4805 elderly patients were qualified for meta-analysis. Pooled results showed that preoperative frailty was linked to the development of PNDs (pooled odds ratio [OR]: 2.40, 95% confidence interval [CI]: 2.05-2.80, P < 0.001) without obvious heterogeneity (P = 0.19, I 2 = 22%). Subgroup analyses revealed that the correlation between preoperative frailty and PNDs was more remarkable in prospective cohort studies (OR: 3.11, 95% CI: 2.47-3.91, P < 0.001) compared to retrospective cohort studies (OR: 1.94, 95% CI: 1.57-2.39, P < 0.001; test for subgroup difference, P = 0.003). In addition, the correlation in patients with cardiac surgery (OR: 3.38, 95% CI: 2.44-4.68, P < 0.001) was more noticeable than noncardiac surgery (OR: 2.17, 95% CI: 1.82-2.59, P < 0.001; test for subgroup difference P = 0.02).

Conclusion

Our results demonstrated that preoperative frailty was independently associated with PNDs in geriatric patients undergoing elective surgery.

Association between modified frailty index and postoperative delirium in patients after cardiac surgery: A cohort study of 2080 older adults

AIM

To evaluate the association between frailty and postoperative delirium (POD) in elderly cardiac surgery patients.

METHODS

A retrospective study was conducted of older patients admitted to the intensive care unit after cardiac surgery at a tertiary academic medical center in Boston from 2008 to 2019. Frailty was measured using the Modified Frailty Index (MFI), which categorized patients into frail (MFI ≥3) and non-frail (MFI = 0-2) groups. Delirium was identified using the confusion assessment method for the intensive care unit and nursing notes. Logistic regression models were used to examine the association between frailty and POD, and odds ratios (OR) with 95% confidence intervals (CI) were calculated.

RESULTS

Of the 2080 patients included (median age approximately 74 years, 30.9% female), 614 were frail and 1466 were non-frail. The incidence of delirium was significantly higher in the frail group (29.2% vs. 16.4%, p < 0.05). After adjustment for age, sex, race, marital status, Acute Physiology Score III (APSIII), sequential organ failure assessment (SOFA), albumin, creatinine, hemoglobin, white blood cell count, type of surgery, alcohol use, smoking, cerebrovascular disease, use of benzodiazepines, and mechanical ventilation, multivariate logistic regression indicated a significantly increased risk of delirium in frail patients (adjusted OR: 1.61, 95% CI: 1.23-2.10, p < 0.001, E-value: 1.85).

CONCLUSIONS

Frailty is an independent risk factor for POD in older patients after cardiac surgery. Further research should focus on frailty assessment and tailored interventions to improve outcomes.

Association of preoperative frailty with the risk of postoperative delirium in older patients undergoing hip fracture surgery: a prospective cohort study

OBJECTIVE

This study aimed to explore the correlation between preoperative frailty and the risk of postoperative delirium (POD) in older patients undergoing hip fracture surgery.

METHODS

In total, 148 patients with hip fractures who were admitted to Tsinghua Changgung Hospital (Beijing, China) between January 2022 and January 2023 were involved in this study. Preoperative frailty scales were assessed, of which the CAM scale was postoperatively administered every morning and evening on days 1, 2, 3, 5, and 7. Binary logistic regression analysis was conducted to determine the correlation between preoperative frailty and the risk of POD.

RESULTS

Among 148 older patients with hip fractures, 71 (48.0%) were identified as preoperative frail and 77 (52.0%) as non-frail. The overall incidence of POD on day 7 was 24.3% (36/148), and preoperative frailty was associated with a significantly higher risk of POD compared with non-frailty (42.3% vs. 7.8%, P < 0.001). The binary logistic regression analysis revealed that preoperative frailty was noted as an independent risk factor for the risk of POD in older patients undergoing hip fracture surgery (P = 0.002).

CONCLUSION

Preoperative frailty increased the risk of POD in older patients undergoing hip fracture surgery.

DISCUSSION

Preoperative assessment of frailty in geriatric hip surgery can timely identify potential risks and provide interventions targeting frailty factors to reduce the incidence of POD in older patients undergoing hip fracture surgery. The findings suggested that preoperative frailty could increase the risk of POD in older patients undergoing hip fracture surgery. Further research is necessary to determine whether perioperative interventions aimed at enhancing frailty can mitigate the risk of POD and improve prognosis in older patients undergoing hip fracture surgery.

The Usefulness of Present-on-Admission Data as an Indicator of Healthcare Quality Evaluation Using the Korean National Hospital Discharge in-Depth Injury Survey Data from 2006 to 2019

Purpose

Comorbidities of a principal diagnosis have varying impacts on disease and require different management depending on the onset timing. This study investigated the usefulness of present-on-admission (POA), specifically focusing on decubitus ulcers, delirium, and hypokalemia, as an indicator of healthcare quality.

Patients and Methods

We analyzed patient discharge data for 14 years from 2006 to 2019 using Korean National Hospital Discharge In-Depth Injury Survey (KNHDIS).

Results

Out of 3,231,731 discharged patients, 19,871 had secondary diagnosis codes for decubitus ulcers (n=10,390, 52.3%), delirium (n=6103, 30.7%), or hypokalemia (n=3378, 17.0%). Analysis of patients with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia revealed notable differences in demographics, including gender distribution, mean age, admission route, insurance type, surgical intervention rates, mortality rates, and length of stay (LOS). Among patients with one of the top 20 principal diagnoses, those with secondary diagnoses of decubitus ulcers, delirium, or hypokalemia exhibited higher odds of surgery, increased mortality risks, and longer LOS compared to those without these secondary diagnoses.

Conclusion

All three of these diseases commonly occur postoperatively or during treatment and thus should be designated as potentially preventable complications that require special attention, and should also be considered as quality-of-care indicators.

Preoperative frailty vs. cognitive impairment: Which one matters most for postoperative delirium among older adults with cancer?

INTRODUCTION

Limited data are available to explore the association between preoperative frailty and cognitive impairment with postoperative delirium among older adults with cancer. We explored this association in a single Comprehensive Cancer Center where postoperative delirium and frailty are assessed in routine care using the Confusion Assessment Method (CAM) and Memorial Sloan Kettering Frailty Index (MSK-FI), respectively.

MATERIALS AND METHODS

Retrospective study on patients with cancer, aged 65+, who underwent surgery from April 2018 to March 2019 with hospital stay ≥1 day. We used logistic regression with postoperative delirium as the outcome, primary predictor MSK-FI, adjusted for age, operative time, and preoperative albumin. As the MSK-FI includes a component related to cognitive impairment, we additionally evaluated the impact of this component, separately from the rest of the score, on the association between frailty and postoperative delirium.

RESULTS

Among 1,257 patients with available MSK-FI and CAM measures, 47 patients (3.7%) had postoperative delirium. Increased frailty was associated with increased risk of postoperative delirium (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.26, 1.81; p < 0.001). However, this was largely related to the effect of cognitive impairment (OR 15.29; 95% CI 7.18; 32.56; p < 0.001). In patients with cognitive impairment, the association between frailty and postoperative delirium was not significant (OR 0.97; 95% CI 0.65, 1.44; p-value = 0.9), as having cognitive impairment put patients at high risk for postoperative delirium even without taking into account the other components of the MSK-FI. While the association between frailty and postoperative delirium in patients with intact cognitive function was statistically significant (OR 1.58; 95% CI 1.27, 1.96; p < 0.001), it was not clinically meaningful, particularly considering the low risk of delirium among patients with intact cognitive function (e.g., 1.3% vs 3.2% for MSK-FI 1 vs 3).

DISCUSSION

Cognitive function should be a greater focus than frailty, as measured by the MSK-FI, in preoperative assessment for the prediction of postoperative delirium.

Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review

Importance

Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups.

Objective

To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting.

Evidence Review

A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium.

Findings

A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity.

Conclusions and Relevance

In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.

Frailty assessment has come to stay: Retrospective analysis pilot study of two frailty scales in oncological older patients undergoing colorectal surgery

INTRODUCTION

Colorectal cancer is a disease of the elderly and its main treatment is surgery. Frailty, a clinical syndrome of decreased reserve, increases with age and has been recognized as a predictive factor for postoperative mortality. Our primary objective was to assess the association between two frailty scores and mortality within the first year after surgery, by retrospectively linking frailty scores to mortality data and comparing the strength of their association with mortality to that of the ASA Classification. The frailty scales used were: the Modified Frailty Index (MFI) and, the Risk Analysis Index-A (RAI-A) and the G8 screening test (G8). As secondary objectives, we assessed the relationship of the frailty scales with morbidity and compared all the scales with the ASA.

MATERIAL AND METHODS

We retrospectively studied 172 patients aged 65 years and older who underwent laparoscopic colorectal surgery for cancer between January 2017 and June 2018, following them up for 1year after surgery.

RESULTS

Both morbidity and mortality were significantly associated with all frailty scale scores (p<.001). The more frailty, the greater probability of prolonged hospital stay, complications, readmissions and emergency department visits. Using each scale, patients were categorized into two groups (frail and non-frail patients). The C-indexes for 1-year mortality with the RAI-A and, MFI and G8 were 0.89 and, 0.86 and 0.86 respectively. On the other hand, ASA status is not strongly associated with mortality, with a C-index of .63.

DISCUSSION

Frailty scores should begin to influence medical and surgical strategies and further research is needed to develop guidelines for interventions in geriatric patients.

Frailty and delirium in hospitalized older adults: A systematic review with meta-analysis

OBJECTIVE

to estimate the prevalence and synthesize diverse evidence about the relationship between frailty and delirium in hospitalized older adults.

METHOD

a systematic review with meta-analysis in which observational studies conducted with older adults about frailty, delirium and hospitalization, were selected without time of language restrictions. The search was conducted in the MEDLINE, EMBASE, CINAHL, Scopus, Web of Science and CENTRAL databases during August 2021. The precepts set forth by the Joanna Briggs Institute (JBI) - Evidence Synthesis Groups were followed. The meta-analysis model estimated the relative risk corresponding to the prevalence of frailty and delirium. The inverse variance method for proportions was used to estimate the prevalence values and relative risks for binary outcomes.

RESULTS

initially, 1,244 articles were identified, of which 26 were included in the meta-analysis (n=13,502 participants), with 34% prevalence of frailty (95% CI:0.26-0.42; I 2=99%; t 2=0.7618, p=0) and 21% for delirium (95% CI:0.17-0,25; I 2=95%; t 2=0.3454, p<0.01). The risk for hospitalized older adults to develop delirium was 66% (RR: 1.66; 95% CI:1.23-2.22; I2=92%; t2=0.4154; p<0.01).

CONCLUSION

34% prevalence of frailty and 21% of delirium in hospitalized older adults, with frailty being an independent risk factor for developing delirium, with an increased chance of 66% when compared to non-frail individuals.

Prehabilitation of elderly frail or pre-frail patients prior to elective surgery (PRAEP-GO): study protocol for a randomized, controlled, outcome assessor-blinded trial

BACKGROUND

Frailty is expressed by a reduction in physical capacity, mobility, muscle strength, and endurance. (Pre-)frailty is present in up to 42% of the older surgical population, with an increased risk for peri- and postoperative complications. Consequently, these patients often suffer from a delayed or limited recovery, loss of autonomy and quality of life, and a decrease in functional and cognitive capacities. Since frailty is modifiable, prehabilitation may improve the physiological reserves of patients and reduce the care dependency 12 months after surgery.

METHODS

Patients ≥ 70 years old scheduled for elective surgery or intervention will be recruited in this multicenter, randomized controlled study, with a target of 1400 participants with an allocation ratio of 1:1. The intervention consists of (1) a shared decision-making process with the patient, relatives, and an interdisciplinary and interprofessional team and (2) a 3-week multimodal, individualized prehabilitation program including exercise therapy, nutritional intervention, mobility or balance training, and psychosocial interventions and medical assessment. The frequency of the supervised prehabilitation is 5 times/week for 3 weeks. The primary endpoint is defined as the level of care dependency 12 months after surgery or intervention.

DISCUSSION

Prehabilitation has been proven to be effective for different populations, including colorectal, transplant, and cardiac surgery patients. In contrast, evidence for prehabilitation in older, frail patients has not been clearly established. To the best of our knowledge, this is currently the largest prehabilitation study on older people with frailty undergoing general elective surgery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04418271 . Registered on 5 June 2020. Universal Trial Number (UTN): U1111-1253-4820.

Association of preoperative frailty with postoperative delirium in elderly orthopedic trauma patients

BACKGROUND

Among elderly orthopedic trauma patients, the prevalence of delirium during hospitalization has been reported to be as high as 60%. Frail elderly patients have an increased risk of delirium after elective surgery; however, such an association remains underexplored among trauma patients.

AIM

Our goal was to investigate whether preoperative frailty is associated with postoperative delirium (POD) in elderly orthopedic trauma patients.

METHODS

We conducted a single-center, retrospective, cross-sectional study. All patients were ≥ 65 years of age and were admitted to the hospital between 01/01/2017 and 08/31/2018 for surgical intervention of a significant extremity fracture. Frailty was assessed using the fatigue, resistance, ambulation, illness, and loss of weight questionnaire. Delirium was assessed using the Confusion Assessment Method. POD was defined as new-onset delirium that occurred within 24 h after surgery. To investigate whether frailty is associated with POD, we performed a multiple variable logistic regression, controlling for biologically relevant confounders.

RESULTS

Five hundred fifty-six patients comprised the analytic cohort. Incidence of POD was 14% (n = 80). Multiple variable regression analysis demonstrated that each unit increment in FRAIL score was associated with a 33% higher likelihood of POD (OR 1.33; 95% CI 1.02-1.72, p = 0.03).

CONCLUSIONS

Our results suggest that preoperative frailty increases the risk of POD in hospitalized, elderly, orthopedic trauma patients. Future studies are needed to determine whether perioperative interventions focused on improving frailty can reduce the risk of POD and improve outcomes in this rapidly growing cohort of patients.

Association between frailty and postoperative delirium: a meta-analysis of cohort study

BACKGROUND

Frailty has been suggested as a possible risk factor for postoperative delirium (POD). However, results of previous studies were not consistent. We performed a meta-analysis of cohort study to evaluate the above association.

METHODS

Relevant studies were obtained via systematic search of PubMed, Embase, SCOPUS, and Web of Science databases. Only studies with multivariate analysis were included. A random-effect model incorporating the potential heterogeneity was used to combine the results.

RESULTS

Fifteen cohort studies including 3250 adult patients who underwent surgery were included, and the prevalence of frailty was 27.1% (880/3250) before surgeries. Overall, POD occurred in 513 patients (15.8%). Pooled results showed that frailty was associated with a higher risk of POD (adjusted odds ratio [OR]: 3.23, 95% confidence interval [CI]: 2.56-4.07, P < 0.001) without significant heterogeneity (P for Cochrane's Q test = 0.25, I² = 18%). Subgroup analyses showed a more remarkable association between frailty and POD in prospective cohort studies (OR: 3.64, 95% CI: 2.95-4.49, P < 0.001) than that in retrospective cohort studies (OR: 2.32, 95% CI: 1.60-3.35, P < 0.001; P for subgroup difference = 0.04). Moreover, the association was not affected by country of the study, age group of the patient, elective or emergency surgeries, cardiac and non-cardiac surgeries, evaluation instruments for frailty, diagnostic methods for POD, or quality score of the study (P for subgroup difference all > 0.05).

CONCLUSIONS

Frailty may be associated with a higher risk of POD in adult population.

Fragilidad y delirium en adultos mayores hospitalizados: revisión sistemática con metanálisis

Resumen Objetivo: estimar la prevalencia y sintetizar evidencias sobre la relación entre fragilidad y delirium en adultos mayores hospitalizados. Método: revisión sistemática con metanálisis en el que se seleccionaron estudios observacionales realizados con adultos mayores sobre fragilidad, delirium y hospitalización, sin recorte temporal ni de idioma. La búsqueda se realizó en las bases de datos MEDLINE, EMBASE, CINAHL, Scopus, Web of Science y CENTRAL en agosto de 2021. Se siguieron los preceptos del Instituto Joanna Briggs (Joanna Briggs Institute, JBI) - Evidence Synthesis Groups. El modelo de metanálisis estimó el riesgo relativo de la prevalencia de fragilidad y delirium. Se utilizó el método de la varianza inversa para proporciones para estimar la prevalencia y el riesgo relativo de los desenlaces binarios. Resultados: inicialmente se identificaron 1.244 artículos, se incluyen en el metanálisis 26 (n=13.502 participantes), la prevalencia de fragilidad fue del 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) y de delirium del 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). El riesgo de que el adulto mayor frágil hospitalizado desarrolle delirium fue del 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusión: los adultos mayores hospitalizados tienen una prevalencia de fragilidad del 34% y de delirium del 21%, la fragilidad es un factor de riesgo independiente para el desarrollo de delirium, cuando se compara a los frágiles con los no frágiles, la probabilidad de delirium de los primeros es de un 66% más.

Fragilidade e delirium em idosos hospitalizados: revisão sistemática com metanálise

Resumo Objetivo: estimar a prevalência e sintetizar evidências sobre a relação entre fragilidade e delirium em idosos hospitalizados. Método: revisão sistemática com metanálise na qual foram selecionados estudos observacionais realizados com idosos sobre fragilidade, delirium e hospitalização, sem recortes temporais e de idioma. A busca foi realizada nas bases de dados MEDLINE, EMBASE, CINAHL, Scopus, Web of Science e CENTRAL durante o mês de agosto de 2021. Foram seguidos os preceitos estabelecidos pelo Joanna Briggs Institute (JBI) - Grupos de Síntese de Evidências.. O modelo de metanálise estimou risco relativo da prevalência de fragilidade e delirium. Utilizou-se método da variância inversa para proporções para estimar as prevalências e risco relativo para desfechos binários. Resultados: identificaram-se, inicialmente, 1.244 artigos, 26 incluídos na metanálise (n=13.502 participantes), sendo a prevalência de fragilidade 34% (IC 95% 0,26 a 0,42; I 2=99%; t 2= 0,7618, p=0) e delirium 21% (IC 95% 0,17 a 0,25; I 2=95%; t 2= 0,3454, p<0,01). O risco do idoso frágil hospitalizado desenvolver delirium foi de 66% (RR 1,66; IC 95% 1,23 a 2,22; I2=92%; t2=0,4154; p<0,01). Conclusão: prevalência de 34% de fragilidade e 21% de delirium em idosos hospitalizados, sendo a fragilidade um fator de risco independente para desenvolvimento de delirium, com um aumento de chance de 66% comparado aos não frágeis.

Assessment of preoperative frailty and identification of patients at risk for postoperative delirium in cardiac intensive care units: a prospective observational study

BACKGROUND

Postoperative delirium (POD) is a common complication that may occur from 24 to 72 h after cardiac surgery. Frailty is a chronic syndrome that leads to a decline in physiological reserve and to disability. The associations between frailty and POD are unclear.

AIMS

To investigate associations between POD and frailty in patients undergoing cardiac surgery and to analyse predictors of POD.

METHODS AND RESULTS

Convenience sampling was used to recruit 152 patients who underwent cardiac surgery in two medical centres in northern Taiwan. Preoperative frailty in these patients was evaluated using Fried's frailty phenotype. Delirium in patients was assessed from postoperative day 1 to day 5 using the confusion assessment method for intensive care units. A total of 152 patients who underwent cardiac surgery included 68 (44.74%) prefrail patients and 21 (13.81%) patients with frailty after the surgery. Ten patients (6.58%) developed delirium after cardiac surgery. The occurrence of delirium peaked at postoperative day 2, and the average duration of delirium was 3 days. A case-control comparison revealed a significant correlation between preoperative frailty and POD. Significant predictors of POD in patients undergoing cardiac surgery included the European System for Cardiac Operative Risk Evaluation II, preoperative arrhythmia, and preoperative anxiety and depression.

CONCLUSION

Preoperative frailty was correlated with POD. Preoperative arrhythmia, anxiety, and depression are predictors of POD. Nurses should perform preoperative assessments of surgical risk and physiological and psychological conditions of patients undergoing cardiac surgery and monitor the occurrence of POD.

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.

Presurgical Screening Improves Risk Prediction for Delirium in Elective Surgery of Older Patients: The PAWEL RISK Study

Introduction: The number of elective surgeries for patients who are over 70 years of age is continuously growing. At the same time, postoperative delirium (POD) is common in older patients (5–60%) depending on predisposing risk factors, such as multimorbidity, cognitive impairment, neurodegenerative disorders and other dementing disorders, and precipitating factors, such as duration of surgery. Knowledge of individual risk profiles prior to elective surgery may help to identify patients at increased risk for development of POD. In this study, clinical and cognitive risk factors for POD were investigated in patients undergoing various elective cardiac and non-cardiac surgeries.

Methods: The PAWEL study is a prospective, interventional trial on delirium prevention. At baseline, 880 inpatients at five surgical centers were recruited for sub-sample PAWEL-R. Multimodal assessments included clinical renal function, medication, American Society of Anesthesiologists (ASA) Physical Status Classification System, geriatric and cognitive assessments, which comprised the Montreal Cognitive Assessment Scale (MoCA), Trail-making Test, and Digit Span backward. Delirium incidence was monitored postoperatively by the Confusion Assessment Method (CAM) and a chart review for up to a week or until discharge. Multivariate regression models and Chi-square Automatic Interaction Detectors (CHAID) analyses were performed using delirium incidence as the primary outcome.

Results: Eighteen risk factors were investigated in elective cardiovascular and orthopedic or general surgery. A total of 208 out of 880 patients (24%) developed POD. A global regression model that included all risk variables predicted delirium incidence with high accuracy (AUC = 0.81; 95% CI 0.77, 0.85). A simpler model (clinical and cognitive variables; model CLIN-COG) of 10 factors that only included surgery type, multimorbidity, renal failure, polypharmacy, ASA, cut-to-suture time, and cognition (MoCA, Digit Span backward, and preexisting dementia), however, exhibited similar predictive accuracy (AUC = 0.80; 95% CI 0.76, 0.84).

Conclusion: The risk of developing POD can be estimated by preoperative assessments, such as ASA classification, expected cut-to-suture time, and short cognitive screenings. This rather efficient approach predicted POD risk over all types of surgery. Thus, a basic risk assessment including a cognitive screen can help to stratify patients at low, medium, or high POD risk to provide targeted prevention and/or management strategies for patients at risk.

Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis

BACKGROUND

Postoperative delirium has eluded attempts to define its complex aetiology and describe specific risk factors. The role of neuroinflammation as a risk factor, determined by measuring blood levels of preoperative 'innate' inflammatory mediator levels, has been investigated. However, results have been conflicting. We conducted a systematic review and meta-analysis of the evidence on associations between preoperative blood levels of inflammatory mediators and postoperative delirium in the older person. Influence of type of surgery was also assessed.

METHODS

Original, low risk of bias studies, published in peer-reviewed journals, which fulfilled the eligibility criteria were included. Seventeen articles fulfilled study criteria. Data extraction, synthesis, and risk of bias analysis were guided by Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) and quality in prognostic studies guidelines. Meta-analyses used a random-effects model. Inflammatory mediators included C-reactive protein, interleukin-6, -8, and -10, tumour necrosis factor-α, insulin-like growth factor-1, cortisol, and neopterin. Surgical groups were cardiac, noncardiac, and hip fracture.

RESULTS

Higher preoperative interleukin-6 was associated with postoperative delirium with a standardised mean difference (95% confidence interval) of 0.33 (0.11-0.56) and P=0.003. Higher neopterin was also associated with postoperative delirium.

CONCLUSIONS

The association of preoperative blood levels of inflammatory mediators with postoperative delirium may be influenced by the type of surgery and the specific mediator. The potential modulating effect of type of surgery, intrinsic brain vulnerability, and the complex interactions between inflammatory mediators and binding proteins will need to be considered in future studies.

CLINICAL TRIAL REGISTRATION

CRD42019159471 (PROSPERO).

Association of preoperative frailty with postoperative delirium after elective brain tumor resection: Retrospective analysis of a prospective cohort

BACKGROUND

Preoperative frailty is associated with poor outcomes in major surgery. Postoperative delirium is common after neurosurgery. To date, the association of preoperative frailty with postoperative delirium after neurosurgery has not been established. We aimed to determine the association between preoperative frailty and postoperative delirium in patients undergoing elective brain tumor resection.

METHODS

We retrospectively analyzed the data of a prospective cohort, consecutively enrolling adult patients admitted to the intensive care unit after elective craniotomy for brain tumor resection under general anesthesia in a tertiary hospital in China from March 1, 2017 to February 2, 2018. Preoperative frailty was evaluated using the modified frailty index. The primary outcome was postoperative delirium, assessed using the Confusion Assessment Method for the Intensive Care Unit. Univariate and multivariable regression analyses were performed to examine the association.

RESULTS

659 patients met inclusion criteria for our analysis. There were 398 (60.4%) non-frail (modified frailty index = 0), 237 (36.0%) pre-frail (modified frailty index = 1-2), and 24 (3.6%) frail (modified frailty index ≥ 3) patients. Of these, 124 (18.8%) developed postoperative delirium. In adjusted analyses, frailty was independently associated with postoperative delirium (odds ratio 1.7, 95% confidence interval 1.0-2.7, P = .032). Frail patients had longer length of hospital stay and higher total costs than non-frail patients.

CONCLUSION

Preoperative frailty is associated with postoperative delirium, length of hospital stay, and total costs in patients undergoing elective brain tumor resection. Preoperative frailty assessment and appropriate management strategies should be involved in the perioperative management of postoperative delirium.

The Association of Preoperative Frailty and Postoperative Delirium: A Meta-analysis

BACKGROUND

Both frailty and postoperative delirium (POD) are common in elective surgical patients 65 years of age and older. However, the association between preoperative frailty and POD remains difficult to characterize owing to the large number of frailty and POD assessment tools used in the literature, only a few of which are validated. Furthermore, some validated frailty tools fail to provide clear score cutoffs for distinguishing frail and nonfrail patients. We performed a meta-analysis to estimate the relationship between preoperative frailty and POD.

METHODS

We searched several major databases for articles that investigated the relationship between preoperative frailty and POD in patients with mean age ≥65 years who were undergoing elective, nonemergent inpatient surgery. Inclusion criteria included articles published in English no earlier than 1999. Both preoperative frailty and POD must have been measured with validated tools using clear cutoff scores for frailty and delirium. Articles were selected and data extracted independently by 2 researchers. Risk of bias (ROBINS-I) and presence of confounders were summarized. Odds ratios (ORs) for POD associated with frailty relative to nonfrailty were computed with adjusted ORs when available. Original estimates were pooled by random effects analysis. Statistical significance was set at 2-sided P < .05.

RESULTS

Nine studies qualified for meta-analysis. The Fried score or a modified version of it was used in 5 studies. Frailty prevalence ranged from 18.6% to 56%. Delirium was assessed with the Confusion Assessment Method (CAM) or Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) in 7 studies, Delirium Observation Scale in 1 study, and Intensive Care Delirium Screening Checklist in 1 study. The incidence of POD ranged from 7% to 56%. ROBINS-I risk of bias was low in 1 study, moderate in 4 studies, serious in 3 studies, and critical in 1 study. Random effects analysis (n = 794) of the OR for POD in frail versus nonfrail patients based on adjusted OR estimates was significant with an OR of 2.14 and a 95% confidence interval of 1.43-3.19. The I2 value was in the low range at 5.5, suggesting small variability from random effects. Funnel-plot analysis did not definitively support either the presence or absence of publication bias.

CONCLUSIONS

This meta-analysis provides evidence for a significant association between preoperative frailty and POD in elective surgical patients age 65 years or older.

Risk Factors for Delirium after Vascular Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Vascular surgery is considered a risk factor for the development of postoperative delirium (POD). In this systematic review we provide a report on the incidence and risk-factors of POD after vascular surgery.

METHODS

A systematic literature search was conducted using Pubmed with the MeSH terms and key words "delirium" or "confusion", "vascular surgery procedures" and "risk factors or "risk assessment". Studies were selected for review after meeting the following inclusion criteria: vascular surgery, POD diagnosed using validated screening tools, and DSM-derived criteria to assess delirium. A meta-analysis was performed for each endpoint if at least two studies could be combined.

RESULTS

Sixteen articles met the abovementioned criteria. The incidence of delirium ranged from 5% to 39%. Various preoperative risk factors were identified that is, age (Random MD 3.96, CI 2.57-5.35), hypertension (Fixed OR 1.30, CI 1.05-1.59), diabetes mellitus (Random OR 2.15, CI 1.30-3.56), hearing impairment (Fixed OR 1.89, CI 1.28-2.81), history of cerebrovascular incident or transient ischemic attack (Fixed OR 2.20, CI 1.68-2.88), renal failure (Fixed OR 1.61, CI 1.19-2.17), and pre-operative low haemoglobin level (fixed MD -0.76, CI -1.04 to -0.47). Intra-operative risk factors were duration of surgery (Random MD 15.68; CI 2.79-28.57), open aneurysm repair (Fixed OR 4.99, CI 3.10-8.03), aortic cross clamping time (fixed MD 7.99, CI 2.56-13.42), amputation surgery (random OR 3.77, CI 2.13-6.67), emergency surgery (Fixed OR 4.84, CI 2.81-8.32) and total blood loss (Random MD 496.5, CI 84.51-908.44) and need for blood transfusion (Random OR 3.72, CI 1.57-8.80). Regional anesthesia on the other hand, had a protective effect. Delirium was associated with longer ICU and hospital length of stay, and more frequent discharge to a care facility.

CONCLUSIONS

POD after vascular surgery is a frequent complication and effect-size pooling supports the concept that delirium is a heterogeneous disorder. The risk factors identified can be used to either design a validated risk factor model or individual preventive strategies for high-risk patients.

Delirium in older patients undergoing aortic valve replacement: incidence, predictors, and cognitive prognosis

Background

Transcatheter aortic valve replacement is increasingly performed in frail older patients who were previously ineligible for a standard surgical procedure. The objectives of this study are to determine delirium incidence, predictors, and relationship with cognitive performance at 3-month follow-up in older patients undergoing aortic valve replacement (AVR).

Methods

Patients (N = 93) aged 70 years and older, undergoing transcatheter (TAVR, N = 66) or surgical (SAVR, N = 27) aortic valve replacement in an academic medical center were enrolled in this prospective cohort study. Delirium was assessed using the Confusion Assessment Method (CAM) on postoperative days 1, 2, 3, and 7. Data on patients’ socio-demographics, functional status (including instrumental activities of daily living (IADL), and surgical risk scores (including Society of Thoracic Surgeons (STS) risk score), were collected at baseline. Cognitive status was assessed with the Mini-Mental Status Exam (MMSE) and the Clock Drawing Test (CDT) at baseline and 3 months after AVR.

Results

Delirium occurred in 21 (23%) patients, within the first three postoperative days in 95% (20/21) of the cases. Delirium incidence was lower in TAVR (13/66 = 20%) than SAVR (8/27 = 30%) patients, but this difference was not statistically significant (p = .298). Patients with delirium had lower baseline cognitive performance (median MMSE score 27.0 ± 3.0 vs 28.0 ± 3.0, p = .029), lower performance in IADL (7.0 vs 8.0, p = .038), and higher STS risk scores (4.7 ± 2.7 vs 2.9 ± 2.3, p = .020). In multivariate analyses, patients with intermediate (score > 3 to ≤8) and high (score > 8) STS risk scores had 4.3 (95%CI 1.2–15.1, p = .025) and 16.5 (95%CI 2.0–138.2, p = .010), respectively, higher odds of incident delirium compared to patients with low (score ≤ 3) STS risk scores. At 3-month follow-up (N = 77), patients with delirium still had lower MMSE score (27.0 ± 8.0 vs 28.0 ± 2.0, p = .007) but this difference did not remain significant once adjusting for baseline MMSE (β-coefficient 1.11, 95%CI [− 3.03–0.80], p = .248).

Conclusions

Delirium occurred in about one in five older patients undergoing AVR, almost essentially within the first three postoperative days. Beside cognitive performance, STS risk score could enhance the identification of high-risk older patients to better target preventative interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02100-5.

Prevention and Management of Delirium in the Intensive Care Unit

Delirium is a debilitating form of brain dysfunction frequently encountered in the intensive care unit (ICU). It is associated with increased morbidity and mortality, longer lengths of stay, higher hospital costs, and cognitive impairment that persists long after hospital discharge. Predisposing factors include smoking, hypertension, cardiac disease, sepsis, and premorbid dementia. Precipitating factors include respiratory failure and shock, metabolic disturbances, prolonged mechanical ventilation, pain, immobility, and sedatives and adverse environmental conditions impairing vision, hearing, and sleep. Historically, antipsychotic medications were the mainstay of delirium treatment in the critically ill. Based on more recent literature, the current Society of Critical Care Medicine (SCCM) guidelines suggest against routine use of antipsychotics for delirium in critically ill adults. Other pharmacologic interventions (e.g., dexmedetomidine) are under investigation and their impact is not yet clear. Nonpharmacologic interventions thus remain the cornerstone of delirium management. This approach is summarized in the ABCDEF bundle (Assess, prevent, and manage pain; Both SAT and SBT; Choice of analgesia and sedation; Delirium: assess, prevent, and manage; Early mobility and exercise; Family engagement and empowerment). The implementation of this bundle reduces the odds of developing delirium and the chances of needing mechanical ventilation, yet there are challenges to its implementation. There is an urgent need for ongoing studies to more effectively mitigate risk factors and to better understand the pathobiology underlying ICU delirium so as to identify additional potential treatments. Further refinements of therapeutic options, from drugs to rehabilitation, are current areas ripe for study to improve the short- and long-term outcomes of critically ill patients with delirium.

Modified fragility index and surgical complexity score are able to predict postoperative morbidity and mortality after cytoreductive surgery for advanced ovarian cancer

OBJECTIVE

The aim of this study was to assess the impact of surgical complexity on postoperative complications and mortality, according to patient's frailty (mFI) following surgery for ovarian cancer.

METHODS

Patients undergoing cytoreductive surgery for ovarian cancer from 2008 to 2018 were identified from our database. A surgical complexity score from 1 to 3 was used to assess the extent of surgery (simple to complex, respectively). mFI with 11 variables, based on mapping the Canadian Study of Health and Aging Frailty Index to the NSQIP comorbidities was evaluated. Data were analyzed using Fisher exact test, independent sample t-test, and logistic regression.

RESULTS

Of 263 patients identified, 33% reported at least one postoperative complication and 6% had severe complications. BMI ≥ 30 (p = 0.04) increased mFI (p = 0.04) and high-complexity surgery (p < 0.001) were independent predictors of severe complications (G3-G5). Patients with high frailty index score (mFI ≥ 3) who underwent intermediate or high-complexity surgery were at higher risk of severe complications ranging from 29.4% to 50.

CONCLUSIONS

The combined evaluation of mFI and surgical complexity expected may identify patients at higher risk for severe morbidity allowing to stratify patients who are less likely to tolerate a surgical extensive treatment.

Influence of Frailty on Outcome in Older Patients Undergoing Non-Cardiac Surgery - A Systematic Review and Meta-Analysis

Frailty is increasingly recognized as a better predictor of adverse postoperative events than chronological age. The objective of this review was to systematically evaluate the effect of frailty on postoperative morbidity and mortality. Studies were included if patients underwent non-cardiac surgery and if frailty was measured by a validated instrument using physical, cognitive and functional domains. A systematic search was performed using EMBASE, MEDLINE, Web of Science, CENTRAL and PubMed from 1990 - 2017. Methodological quality was assessed using an assessment tool for prognosis studies. Outcomes were 30-day mortality and complications, one-year mortality, postoperative delirium and discharge location. Meta-analyses using random effect models were performed and presented as pooled risk ratios with confidence intervals and prediction intervals. We included 56 studies involving 1.106.653 patients. Eleven frailty assessment tools were used. Frailty increases risk of 30-day mortality (31 studies, 673.387 patients, risk ratio 3.71 [95% CI 2.89-4.77] (PI 1.38-9.97; I2=95%) and 30-day complications (37 studies, 627.991 patients, RR 2.39 [95% CI 2.02-2.83). Risk of 1-year mortality was threefold higher (six studies, 341.769 patients, RR 3.40 [95% CI 2.42-4.77]). Four studies (N=438) reported on postoperative delirium. Meta-analysis showed a significant increased risk (RR 2.13 [95% CI 1.23-3.67). Finally, frail patients had a higher risk of institutionalization (10 studies, RR 2.30 [95% CI 1.81- 2.92]). Frailty is strongly associated with risk of postoperative complications, delirium, institutionalization and mortality. Preoperative assessment of frailty can be used as a tool for patients and doctors to decide who benefits from surgery and who doesn't.

Physical Performance and Risk of Postoperative Delirium in Older Adults Undergoing Aortic Valve Replacement

Background

Delirium is a major risk factor for poor recovery after surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). It is unclear whether preoperative physical performance tests improve delirium prediction.

Objective

To examine whether physical performance tests can predict delirium after SAVR and TAVR, and adapt an existing delirium prediction rule for cardiac surgery, which includes Mini-Mental State Examination (MMSE), depression, prior stroke, and albumin level.

Design

Prospective cohort, 2014-2017.

Setting

Single academic center.

Subjects

A total of 187 patients undergoing SAVR (n=77) or TAVR (n=110).

Methods

The Short Physical Performance Battery (SPPB) score was calculated based on gait speed, balance, and chair stands (range: 0-12 points, lower scores indicate poor performance). Delirium was assessed using the Confusion Assessment Method. We fitted logistic regression to predict delirium using SPPB components and risk factors of delirium.

Results

Delirium occurred in 35.8% (50.7% in SAVR and 25.5% in TAVR). The risk of delirium increased for lower SPPB scores: 10-12 (28.2%), 7-9 (34.5%), 4-6 (37.5%) and 0-3 (44.1%) (p-for-trend=0.001). A model that included gait speed <0.46 meter/second (OR, 2.7; 95% CI, 1.2-6.4), chair stands time ≥11.2 seconds (OR, 3.5; 95% CI, 1.0-12.4), MMSE <24 points (OR, 2.9; 95% CI, 1.3-6.4), isolated SAVR (OR, 5.4; 95% CI, 2.1-13.8), and SAVR and coronary artery bypass grafting (OR, 15.8; 95% CI, 5.5-45.7) predicted delirium better than the existing prediction rule (C statistics: 0.71 vs 0.61; p=0.035).

Conclusion

Assessing physical performance, in addition to cognitive function, can help identify high-risk patients for delirium after SAVR and TAVR.

Incidence and risk factors for acute delirium in older patients with a hip fracture: A retrospective cohort study

This retrospective cohort study aimed to determine the incidence, and preoperative, intraoperative, and postoperative risk factors for postoperative delirium in older patients undergoing surgical fixation of a hip fracture. Electronic medical records were examined of 260 patients who underwent a surgical fixation of a hip fracture between June 2017 and October 2018 at a university-affiliated tertiary care hospital in Victoria, Australia. Demographic, clinical, and perioperative data were examined for potential risk factors for postoperative delirium. Of the 260 patients, 63 patients (24.2%) developed delirium postoperatively. Univariate logistic regression analysis indicated that advanced age, comorbidity, cognitive impairment, dementia, American Society of Anesthesiologists score, and antipsychotic usage were significant risk factors for delirium, while doses of paracetamol, fentanyl, and diazepam showed complex associations. Multivariate logistic regression analysis determined comorbidity and cognitive impairment as independent risk factors for the development of delirium. This study demonstrates the importance of evaluation of medications prescribed in the perioperative period as modifiable risk factors, in order to identify patients at high risk of delirium and enable targeted monitoring and treatment during patients' hospitalization.

American Society for Enhanced Recovery and Perioperative Quality Initiative Joint Consensus Statement on Postoperative Delirium Prevention

Postoperative delirium is a geriatric syndrome that manifests as changes in cognition, attention, and levels of consciousness after surgery. It occurs in up to 50% of patients after major surgery and is associated with adverse outcomes, including increased hospital length of stay, higher cost of care, higher rates of institutionalization after discharge, and higher rates of readmission. Furthermore, it is associated with functional decline and cognitive impairments after surgery. As the age and medical complexity of our surgical population increases, practitioners need the skills to identify and prevent delirium in this high-risk population. Because delirium is a common and consequential postoperative complication, there has been an abundance of recent research focused on delirium, conducted by clinicians from a variety of specialties. There have also been several reviews and recommendation statements; however, these have not been based on robust evidence. The Sixth Perioperative Quality Initiative (POQI-6) consensus conference brought together a team of multidisciplinary experts to formally survey and evaluate the literature on postoperative delirium prevention and provide evidence-based recommendations using an iterative Delphi process and Grading of Recommendations Assessment, Development and Evaluation (GRADE) Criteria for evaluating biomedical literature.

Preoperative Depression and Plasma Cortisol Levels as Predictors of Delirium after Cardiac Surgery

BACKGROUND

Delirium is common in old patients who undergo cardiac surgery, and it is associated with adverse outcomes. The genesis of delirium is thought to be multi-factorial, but it is still not well understood. Symptoms of depression and elevated cortisol level have been described in some previous studies as factors associated with delirium, suggesting a shared pathophysiology.

AIMS

The objective of the present study was to determine whether preoperative depression symptoms and increased cortisol level represent risk factors for delirium after cardiac surgery.

METHODS

We performed a prospective cohort study in 183 patients aged >50 years undergoing elective cardiac surgery. The Geriatric Depression Scale (GDS) was used to assess patients for depressive symptoms before surgery. Preoperative plasma cortisol levels were available in 145 participants. Delirium was diagnosed using the Confusion Assessment Method for Intensive Care Unit (CAM-ICU) during the first 7 days after surgery. Spearman correlation was used for correlations between GDS, Mini-Mental State Examination (MMSE), Charlson comorbidity index, and age. Binary logistic regression was used to determine whether GDS and cortisol levels predict postoperative delirium.

RESULTS

Delirium occurred in 60 patients out of 183 (32.8%) included and lasted 2.3 days (SD 1.36). GDS was correlated with age (p = 0.001) and comorbidity index (p = 0.003) and inversely correlated with MMSE score (p < 0.001). Higher preoperative GDS scores were associated with incidence of delirium in the postoperative period (p = 0.002). The association was significant after controlling for age, MMSE score, history of stroke, and Charlson comorbidity index (p = 0.045). Preoperative cortisol level was not associated with the development of postoperative delirium.

CONCLUSION

Our results suggest that a higher preoperative depression score is associated with an increased risk of postoperative delirium. On the other hand, preoperative plasma cortisol level does not seem to be a predictor of delirium after surgery. Further studies are needed to determine the potential of preoperative depression treatment to prevent postoperative delirium.

The impact of frailty on acute care general surgery patients: A systematic review

BACKGROUND

Frailty may predict negative health outcomes more accurately than chronological age alone. This review examines evidence for the impact of frailty on adverse outcomes in patients admitted with an acute care general surgery (ACS) diagnosis.

METHODS

A systematic literature search for studies reporting frailty and outcomes after admission with an ACS diagnosis was performed. We searched PubMed and SCOPUS from inception until September 2017.

RESULTS

A total of 8,668 records were screened, of which seven studies examined the relationship between frailty and outcomes in ACS patients. Frailty was associated with higher 30-day mortality patients (odds ratio, 3.04; 95% confidence interval, 2.67-3.46; p < 0.01), postoperative complications, length of stay, institutional discharge, and critical care admission.

CONCLUSIONS

There is emerging evidence that frailty is associated with worse outcomes in patients with an unplanned admission due to an ACS diagnosis. Further investigation is warranted with regard to how frailty may impact patients with an acute illness more severely.

LEVEL OF EVIDENCE

Systematic review, level III.

Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery

BACKGROUND

The prevalence of delirium and its impact on outcomes after emergency general surgery (EGS) remain unexplored. The aims of our study were to assess the impact of frailty on delirium and the impact of delirium on outcomes in geriatric EGS patients.

STUDY DESIGN

We performed a 1-year (2017) prospective cohort analysis of all geriatric (age ≥ 65 years) patients who underwent EGS. Frailty was calculated using the Emergency General Surgery-Specific Frailty Index (ESFI). Delirium was assessed using the Confusion Assessment Method (CAM). Patients were dichotomized as delirious or non-delirious. We performed regression analysis controlling for demographics, admission vitals, American Society of Anesthesiologists (ASA) score, comorbidity, and the diagnosis and type of surgery.

RESULTS

A total of 163 patients underwent emergency general surgery and were included. Mean age was 71 ± 7 years, and 59% were male. Overall, the incidence of postoperative delirium was 26%. Patients who developed postoperative delirium were more likely to be frail (40% vs 14%, p < 0.01), on more than 3 medications (29% vs 18%, p < 0.01), and were more likely to have 3 or more comorbidities (32% vs 21%, p < 0.01). On regression analysis, frail status (odds ratio [OR] 3.7 [2.4-4.2], p < 0.01) and receiving more than 3 medications (OR 1.3 [range 1.1-1.4], p < 0.01) were independent predictors of developing postoperative delirium. An episode of delirium was associated with longer hospital length of stay (LOS) (6 days vs 3 days, p < 0.01), higher odds of ICU admission (OR 2 [1.3-4.5], p < 0.01), longer ICU LOS (2 days vs 1 day, p < 0.01), and higher odds of unplanned intubation (OR 1.8 [1.2-3.4], p < 0.01).

CONCLUSIONS

The incidence of delirium after EGS was 26%. Frailty and polypharmacy were associated with increased risk of delirium. Delirium appears to be associated with higher rates of in-hospital adverse events.

Accuracy and Feasibility of Clinically Applied Frailty Instruments before Surgery

Background

A barrier to routine preoperative frailty assessment is the large number of frailty instruments described. Previous systematic reviews estimate the association of frailty with outcomes, but none have evaluated outcomes at the individual instrument level or specific to clinical assessment of frailty, which must combine accuracy with feasibility to support clinical practice.

Methods

The authors conducted a preregistered systematic review (CRD42019107551) of studies prospectively applying a frailty instrument in a clinical setting before surgery. Medline, Excerpta Medica Database, Cochrane Library and the Comprehensive Index to Nursing and Allied Health Literature, and Cochrane databases were searched using a peer-reviewed strategy. All stages of the review were completed in duplicate. The primary outcome was mortality and secondary outcomes reflected routinely collected and patient-centered measures; feasibility measures were also collected. Effect estimates were pooled using random-effects models or narratively synthesized. Risk of bias was assessed.

Results

Seventy studies were included; 45 contributed to meta-analyses. Frailty was defined using 35 different instruments; five were meta-analyzed, with the Fried Phenotype having the largest number of studies. Most strongly associated with: mortality and nonfavorable discharge was the Clinical Frailty Scale (odds ratio, 4.89; 95% CI, 1.83 to 13.05 and odds ratio, 6.31; 95% CI, 4.00 to 9.94, respectively); complications was associated with the Edmonton Frail Scale (odds ratio, 2.93; 95% CI, 1.52 to 5.65); and delirium was associated with the Frailty Phenotype (odds ratio, 3.79; 95% CI, 1.75 to 8.22). The Clinical Frailty Scale had the highest reported measures of feasibility.

Conclusions

Clinicians should consider accuracy and feasibility when choosing a frailty instrument. Strong evidence in both domains support the Clinical Frailty Scale, while the Fried Phenotype may require a trade-off of accuracy with lower feasibility.

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Impact of frailty on short-term outcomes in patients undergoing transsphenoidal pituitary surgery

OBJECTIVE

Frailty, a state of decreased physiological reserve, has been shown to significantly impact outcomes of surgery. The authors sought to examine the impact of frailty on the short-term outcomes of patients undergoing transsphenoidal pituitary surgery.

METHODS

Weighted data from the 2000-2014 National (Nationwide) Inpatient Sample were studied. Patients diagnosed with pituitary tumors or disorders who had undergone transsphenoidal pituitary surgery were identified. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Standard descriptive techniques and matched propensity score analyses were used to explore the odds ratios of postoperative complications, discharge dispositions, and costs.

RESULTS

A total of 115,317 cases were included in the analysis. Frailty was present in 1.48% of cases. The mean age of frail versus non-frail patients was 57.14 ± 16.96 years (mean ± standard deviation) versus 51.91 ± 15.88 years, respectively (p < 0.001). A greater proportion of frail compared to non-frail patients had an age ≥ 65 years (37.08% vs 24.08%, respectively, p < 0.001). Frail patients were more likely to be black or Hispanic (p < 0.001), possess Medicare or Medicaid insurance (p < 0.001), belong to lower-median-income groups (p < 0.001), and have greater comorbidity (p < 0.001). Results of propensity score-matched multivariate analysis revealed that frail patients were more likely to develop fluid and electrolyte disorders (OR 1.61, 95% CI 1.07-2.43, p = 0.02), intracranial vascular complications (OR 2.73, 95% CI 1.01-7.49, p = 0.04), mental status changes (OR 3.60, 95% CI 1.65-7.82, p < 0.001), and medical complications including pulmonary insufficiency (OR 2.01, 95% CI 1.13-4.05, p = 0.02) and acute kidney failure (OR 4.70, 95% CI 1.88-11.74, p = 0.01). The mortality rate was higher among frail patients (1.46% vs 0.37%, p < 0.001). Frail patients also demonstrated a greater likelihood for nonroutine discharges (p < 0.001), higher mean total charges ($109,614.33 [95% CI $92,756.09-$126,472.50] vs $56,370.35 [95% CI $55,595.72-$57,144.98], p < 0.001), and longer hospitalizations (9.27 days [95% CI 7.79-10.75] vs 4.46 days [95% CI 4.39-4.53], p < 0.001).

CONCLUSIONS

Frailty in patients undergoing transsphenoidal pituitary surgery is associated with worse postoperative outcomes and higher costs, indicating that state's potential role in routine preoperative risk stratification.

Rapid in-person cognitive screening in the preoperative setting: Test considerations and recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile a comprehensive list of cognitive screening tools used within primary care and preoperative settings. This Recommendations Statement: 1. summarizes a review of the literature on existing cognitive screening tools used within preoperative settings; 2. discusses factors to consider when selecting cognitive screening tools in a preoperative environment; and 3. includes a work flow diagram to guide use of these screening measures. Methodology involved searching peer-reviewed literature for 29 cognitive screening tools which were identified from the literature that fit inclusion criteria. Of these 29, seven tests have been used in preoperative settings and are discussed. These seven had an average administration time ranging from one to ten minutes. Memory, language, and attention were the most commonly evaluated cognitive domains. Most had adequate sensitivity and specificity to detect cognitive impairment/dementia. While information on the psychometric properties of these tools is limited, the tools discussed are appropriate for lay examiners, are short in duration, and accessible for free or at a low cost. We describe factors that must be considered prior to instrument selection.

Rapid In-Person Cognitive Screening in the Preoperative Setting: Test Considerations and Recommendations from the Society for Perioperative Assessment and Quality Improvement (SPAQI)

There are few cognitive screening tools appropriate for fast-paced settings with limited staffing, and particularly in preoperative evaluation clinics. The Society for Perioperative Assessment and Quality Improvement (SPAQI) convened experts in neuropsychology, geriatric medicine, and anesthesiology to conduct a review of the literature and compile a comprehensive list of cognitive screening tools used within primary care and preoperative settings. This Recommendations Statement: 1. summarizes a review of the literature on existing cognitive screening tools used within preoperative settings; 2. discusses factors to consider when selecting cognitive screening tools in a preoperative environment; and 3. includes a work flow diagram to guide use of these screening measures. Methodology involved searching peer-reviewed literature for 29 cognitive screening tools which were identified from the literature that fit inclusion criteria. Of these 29, seven tests have been used in preoperative settings and are discussed. These seven had an average administration time ranging from one to ten minutes. Memory, language, and attention were the most commonly evaluated cognitive domains. Most had adequate sensitivity and specificity to detect cognitive impairment/dementia. While information on the psychometric properties of these tools is limited, the tools discussed are appropriate for lay examiners, are short in duration, and accessible for free or at a low cost. We describe factors that must be considered prior to instrument selection.

Geriatric Medicine Research Collaborative. Delirium is prevalent in older hospital inpatients and associated with adverse outcomes: results of a prospective multi-centre study on World Delirium Awareness Day

BACKGROUND

Delirium is a common severe neuropsychiatric condition secondary to physical illness, which predominantly affects older adults in hospital. Prior to this study, the UK point prevalence of delirium was unknown. We set out to ascertain the point prevalence of delirium across UK hospitals and how this relates to adverse outcomes.

METHODS

We conducted a prospective observational study across 45 UK acute care hospitals. Older adults aged 65 years and older were screened and assessed for evidence of delirium on World Delirium Awareness Day (14th March 2018). We included patients admitted within the previous 48 h, excluding critical care admissions.

RESULTS

The point prevalence of Diagnostic and Statistical Manual on Mental Disorders, Fifth Edition (DSM-5) delirium diagnosis was 14.7% (222/1507). Delirium presence was associated with higher Clinical Frailty Scale (CFS): CFS 4-6 (frail) (OR 4.80, CI 2.63-8.74), 7-9 (very frail) (OR 9.33, CI 4.79-18.17), compared to 1-3 (fit). However, higher CFS was associated with reduced delirium recognition (7-9 compared to 1-3; OR 0.16, CI 0.04-0.77). In multivariable analyses, delirium was associated with increased length of stay (+ 3.45 days, CI 1.75-5.07) and increased mortality (OR 2.43, CI 1.44-4.09) at 1 month. Screening for delirium was associated with an increased chance of recognition (OR 5.47, CI 2.67-11.21).

CONCLUSIONS

Delirium is prevalent in older adults in UK hospitals but remains under-recognised. Frailty is strongly associated with the development of delirium, but delirium is less likely to be recognised in frail patients. The presence of delirium is associated with increased mortality and length of stay at one month. A national programme to increase screening has the potential to improve recognition.

You Are Only as Frail as Your Arteries: Prehabilitation of Elderly Surgical Patients

Purpose of Review

To discuss the concept of prehabilitation for the elderly frail surgical patient as well as strategies to improve preoperative functional capacity and vascular function to decrease postoperative complications.

Recent Findings

Frailty is associated with poor surgical outcomes yet there is no consensus on how frailty should be measured or mitigated in the preoperative period. Prehabilitation, or improving functional capacity prior to surgery typically through exercise, has been shown to be an effective strategy to decrease preoperative frailty and improves surgical outcomes. Use of remote ischemic preconditioning (RIPC) may serve as an alternative to exercise in this fragile patient population.

Summary

Prehabilitation programs using strategies targeted at improving vascular function may decrease frailty in the preoperative period and improve surgical outcomes in the elderly population.

Multivariate risk factor analysis and literature review of postoperative deterioration in Karnofsky Performance Scale score in elderly patients with skull base meningioma

OBJECTIVE Elderly patients are particularly at risk for severe morbidity following surgery. Among the various risk factors, age and skull base location of meningioma are known to be poor prognostic factors in meningioma surgery. The authors conducted this study to analyze significant preoperative risk factors in elderly patients with skull base meningioma. METHODS A total of 265 elderly patients (≥ 65 years old) with meningioma were surgically treated at the authors' institute and affiliated hospitals between 2000 and 2016, and these cases were reviewed. Among them, 57 patients with skull base meningioma were evaluated. Among the various risk factors, the authors analyzed age, sex, Karnofsky Performance Scale (KPS) score, American Society of Anesthesiologists score, and tumor size, location, and pathology. Body mass index (BMI) and serum albumin were investigated as the frailty factors. The authors also reviewed 11 surgical studies of elderly patients ≥ 60 years old with meningioma. RESULTS The mean age was 72.4 ± 5.7 years, and 42 patients were female (73.6%). The mean size of meningioma was 36.6 ± 14.8 mm at the maximum diameter, and the mean follow-up period was 31.1 ± 31.5 months. (The continuous variables are expressed as the mean ± SD.) Histopathological investigation revealed a higher incidence (71.9%) of WHO Grade I. The rates of deterioration after surgery, at 3 months, and at 1 year were 33.3%, 37.3%, and 39.1%, respectively. Univariate analysis revealed location, preoperative KPS score, BMI level 2, and serum albumin level (p = 0.010, 0.017, 0.0012, and 0.0019, respectively) to be poor prognostic factors. Multivariate analysis revealed that location (p = 0.038) and BMI (p = 0.035) were risk factors for KPS score deterioration immediately after surgery. According to the 11 papers reviewed, the median rate (25th-75th percentile) of skull base-related location was 43.5% (39.6-47.75); for asymptomatic status the mean was 24%; and for mortality at 3 months and 1 year the medians were 6.3% (0.7-7.1) and 8% (4.8-9.4), respectively. CONCLUSION Careful preoperative assessment based on the frailty concept was essential for better outcome in elderly patients with skull base meningioma. The BMI is appropriate as a quantitative factor for measure of frailty, particularly in elderly individuals with skull base meningioma. Further prospective randomized controlled trials are necessary to validate frailty as a preoperative risk factor. Not only patient selection but also surgical timing was an important factor.

Association of Integrated Care Coordination With Postsurgical Outcomes in High-Risk Older Adults: The Perioperative Optimization of Senior Health (POSH) Initiative

Importance

Older adults undergoing elective surgery experience higher rates of preventable postoperative complications than younger patients.

Objective

To assess clinical outcomes for older adults undergoing elective abdominal surgery via a collaborative intervention by surgery, geriatrics, and anesthesia focused on perioperative health optimization.

Design, Setting, and Participants

Perioperative Optimization of Senior Health (POSH) is a quality improvement initiative with prospective data collection. Participants in an existing geriatrics-based clinic within a single-site academic health center were included if they were at high risk for complications (ie, older than 85 years or older than 65 years with cognitive impairment, recent weight loss, multimorbidity, or polypharmacy) undergoing elective abdominal surgery. Outcomes were compared with a control group of patients older than 65 years who underwent similar surgeries by the same group of general surgeons immediately before implementation of POSH.

Main Outcomes and Measures

Primary outcomes included length of stay, 7- and 30-day readmissions, and level of care at discharge. Secondary outcomes were delirium and other major postoperative complications. Outcomes data were derived from institutional databases linked with electronic health records and billing data sets.

Results

One hundred eighty-three POSH patients were compared with 143 patients in the control group. On average, patients in the POSH group were older compared with those in the control group (75.6 vs 71.9 years; P < .001; 95% CI, 2.27 to 5.19) and had more chronic conditions (10.6 vs 8.5; P = .001; 95% CI, 0.86 to 3.35). Median length of stay was shorter among POSH patients (4 days vs 6 days; P < .001; 95% CI, -1.06 to -4.21). Patients in the POSH group had lower readmission rates at 7 days (5 of 180 [2.8%] vs 14 of 142 [9.9%]; P = .007; 95% CI, 0.09 to 0.74) and 30 days (14 of 180 [7.8%] vs 26 of 142 [18.3%]; P = .004; 95% CI, 0.19 to 0.75) and were more likely to be discharged home with self-care (114 of 183 [62.3%] vs 73 of 143 [51.1%]; P = .04; 95% CI, 1.02 to 2.47). Patients in the POSH group experienced fewer mean number of complications (0.9 vs 1.4; P < .001; 95% CI, -0.13 to -0.89) despite higher rates of documented delirium (52 of 183 [28.4%] vs 8 of 143 [5.6%]; P < .001; 95% CI, 3.06 to 14.65). A greater proportion of POSH patients underwent laparoscopic procedures (92 of 183 [50%] vs 55 of 143 [38.5%]; P = .001; 95% CI, 1.04 to 2.52). Tests for interactions between POSH patients and procedure type were insignificant for all outcomes.

Conclusions and Relevance

Despite higher mean age and morbidity burden, older adults who participated in an interdisciplinary perioperative care intervention had fewer complications, shorter hospitalizations, more frequent discharge to home, and fewer readmissions than a comparison group.

Associations between Frailty and Delirium among Older Patients Admitted to an Emergency Department

BACKGROUND

Switzerland's demographic trends show, as elsewhere on the planet, increasing numbers of older and very old adults. This suggests that its healthcare system will suffer serious repercussions, including in the use of care and especially the use of emergency services. Significant numbers of older adults will be at risk of developing multiple chronic conditions including one or more geriatric syndromes, such as frailty and delirium. Few studies to date have documented associations between frailty and delirium.

AIM

To explore the relationships between frailty and delirium in older adult patients consulting (n = 114) at an emergency department (ED) in Switzerland.

METHOD

A cross-sectional study was conducted in a peripheral hospital ED in the French-speaking part of Switzerland. Frailty was assessed using the Tilburg Frailty Indicator (TFI). Delirium was assessed using the Confusion Assessment Method (CAM). Participants' cognitive states were assessed using the 6-item Cognitive Impairment Test (6CIT) and the Informant Questionnaire on Cognitive Decline in the Elderly (IQ-CODE), completed by the participant's most significant informal caregiver.

RESULTS

The mean participant age was 77.6 years (SD = 7.7); the majority of the subjects were women (54%). The participants took an average of 4.7 different medications a day (SD = 3.2, median = 4). More than half (62%) of the participants were frail; 2 and 14% presented signs and symptoms of delirium and subsyndromal delirium, respectively. A weak but significant association between scores for frailty and delirium (p < 0.05) was demonstrated, and clinical observation confirmed this. A 4-h follow-up measurement of delirium in the ED revealed no significant or clinical difference.

CONCLUSION

Although the literature describes strong associations between frailty and delirium in surgical units and community care settings, the present study only demonstrated a weak-to-moderate association between frailty and delirium in our ED.