1
|
Xiong X, Shao Y, Chen D, Chen B, Lan X, Shi J. Effect of Esketamine on Postoperative Delirium in Patients Undergoing Cardiac Valve Replacement with Cardiopulmonary Bypass: A Randomized Controlled Trial. Anesth Analg 2024; 139:743-753. [PMID: 38446699 DOI: 10.1213/ane.0000000000006925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
BACKGROUND The aim of this study was to investigate the effects of esketamine on the risk of postoperative delirium (POD) in adults undergoing on-pump cardiac valve surgery. METHODS In this randomized, triple-blind, controlled trial, 116 adult patients with an American Society of Anesthesiologists (ASA) grade Ⅱ or Ⅲ and a New York Heart Association (NYHA) grade Ⅱ or Ⅲ who underwent cardiac valve surgery with cardiopulmonary bypass were included. Esketamine (0.25 mg/kg) or normal saline was administered intravenously before anesthesia induction. The primary outcome was POD, defined as a positive delirium assessment according to the 3-minute confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) on a twice-daily basis for 7 days after surgery. Delirium duration and the delirium subtype were also recorded. The cognitive status of patients was measured according to the Mini-Mental State Examination at baseline, discharge, 30 days postoperatively and 3 months postoperatively. RESULTS A total of 112 patients (mean age, 52 years; 53.6% female) were enrolled; 56 were assigned to receive esketamine, and 56 were assigned to receive placebo. POD occurred in 13 (23.2%) patients in the esketamine group and in 25 (44.6%) patients in the placebo group (relative risk [RR], 0.52, 95% confidence interval [CI], 0.28-0.91; P = .018). Thirteen patients (23.2%) in the esketamine group and 24 (42.9%) patients in the placebo group had multiple episodes of delirium (RR, 0.54, 95% CI, 0.28-0.92), and 13 (23.2%) vs 22 (39.3%) patients exhibited the hyperactive subtype. CONCLUSIONS A single dose of esketamine (0.25 mg/kg) injected intravenously before anesthesia induction reduced the incidence of delirium in relatively young patients with ASA grade Ⅱ or Ⅲ who underwent on-pump cardiac surgery.
Collapse
Affiliation(s)
- Xinglong Xiong
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Yi Shao
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Dongxu Chen
- Department of Anesthesiology, West China Second Hospital, Sichuan University, Chengdu, P. R. China
| | - Bo Chen
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Xin Lan
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| | - Jing Shi
- From the Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, P. R. China
| |
Collapse
|
2
|
Hartog M, Beishuizen SJE, Togo R, van Bruchem-Visser RL, van Eijck CHJ, Mattace-Raso FUS, Pek CJ, de Wilde RF, Groot Koerkamp B, Polinder-Bos HA. Comprehensive Geriatric Assessment, Treatment Decisions, and Outcomes in Older Patients Eligible for Pancreatic Surgery. J Surg Oncol 2024. [PMID: 39290062 DOI: 10.1002/jso.27862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 07/08/2024] [Accepted: 08/18/2024] [Indexed: 09/19/2024]
Abstract
INTRODUCTION Periampullary cancer has a poor prognosis. Surgical resection is a potentially curative but high-risk treatment. Comprehensive geriatric assessment (CGA) can inform treatment decisions, but has not yet been evaluated in older patients eligible for pancreatic surgery. METHODS This prospective observational study included patients ≥ 70 years of age eligible for pancreatic surgery. Frailty was defined as impairment in at least two of five domains: somatic, psychological, functional, nutritional, and social. Outcomes included postoperative complications, functional decline, and mortality. RESULTS Of the 88 patients included, 87 had a complete CGA. Sixty-five patients (75%) were frail and 22 (25%) were non-frail. Frail patients were more likely to receive nonsurgical treatment (43.1% vs. 9.1% p = 0.004). Fifty-seven patients underwent surgery, of which 52 (59%) underwent pancreaticoduodenectomy. The incidence of postoperative delirium was three times higher in frail patients (29.7% vs. 0%, p = 0.005). The risk of mortality was three times higher in frail patients (HR: 3.36, 95% CI: 1.43-7.89, p = 0.006). CONCLUSION Frailty is common in older patients eligible for pancreatic surgery and is associated with treatment decision, a higher incidence of delirium and a three times higher risk of all-cause mortality. CGA can contribute to shared decision-making and optimize perioperative care in older patients.
Collapse
Affiliation(s)
- Marij Hartog
- Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Reon Togo
- Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Rozemarijn L van Bruchem-Visser
- Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Casper H J van Eijck
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Francesco U S Mattace-Raso
- Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Chulja J Pek
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roeland F de Wilde
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bas Groot Koerkamp
- Department of Surgery, Erasmus MC Cancer Institute, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Harmke A Polinder-Bos
- Department of Internal Medicine, Division of Geriatric Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
3
|
Denkinger M, Wirth R, van den Heuvel D, Leinert C, Gosch M. [Care models for older people based on a case study-Geriatrics as an active discipline]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:880-889. [PMID: 39120708 DOI: 10.1007/s00108-024-01758-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/04/2024] [Indexed: 08/10/2024]
Abstract
Geriatrics can enable and monitor a holistic care of older people through a comprehensive geriatric assessment in a structured way. Therefore, it must be integrated much more closely with preventive, rehabilitative and acute care units. Geriatrics are not seen in any aspects as a replacement for general practitioners or in-hospital structures but much more as a supplement to them. With its function-oriented concept, geriatrics can best coordinate the demographically necessary triage between prevention, acute treatment, rehabilitation and palliative care, thus avoiding undertreatment and overtreatment. This can only succeed in collaboration with general practitioners and specialist colleagues. The article categorizes geriatric care structures, such as preventive home visits, acute complex medical treatment, delirium prevention, outpatient and inpatient rehabilitation services based on a case example and makes proposals for structural changes that urgently need to be considered in the current healthcare reform, such as outpatient geriatric centers (AGZ).
Collapse
Affiliation(s)
- Michael Denkinger
- Geriatrisches Zentrum an der AGAPLESION Bethesda Klinik Ulm, Zollernring 26, 89073, Ulm, Deutschland.
- Institut für Geriatrische Forschung, Universitätsklinikum Ulm, Ulm, Deutschland.
| | - Rainer Wirth
- Klinik für Altersmedizin und Frührehabilitation, Marien Hospital Herne - Universitätsklinikum der Ruhr-Universität Bochum, Herne, Deutschland
| | | | - Christoph Leinert
- Geriatrisches Zentrum an der AGAPLESION Bethesda Klinik Ulm, Zollernring 26, 89073, Ulm, Deutschland
- Institut für Geriatrische Forschung, Universitätsklinikum Ulm, Ulm, Deutschland
| | - Markus Gosch
- Medizinische Klinik 2, Schwerpunkt Geriatrie, Klinikum Nürnberg, Paracelsus Medizinische Privatuniversität Nürnberg, Nürnberg, Deutschland
| |
Collapse
|
4
|
Meng L, Zhao X, Sun Y, Cheng S, Bao L, Fang K, Yu Q, Zheng Y, Wang J, Luo M, Gunderman D, Vuckovic N, Sidhu AS, Li J, Li G, Wolfe JW, Liu Z, Adams DC. Characteristics associated with effectiveness in postoperative delirium research: a systematic review of randomised controlled trials with meta-regression and meta-analysis. Br J Anaesth 2024; 133:565-583. [PMID: 38969535 DOI: 10.1016/j.bja.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 05/28/2024] [Accepted: 05/30/2024] [Indexed: 07/07/2024] Open
Abstract
BACKGROUND Postoperative delirium remains prevalent despite extensive research through randomised trials aimed at reducing its incidence. Understanding trial characteristics associated with interventions' effectiveness facilitates data interpretation. METHODS Trial characteristics were extracted from eligible trials identified through two systematic literature searches. Multivariable meta-regression was used to investigate trial characteristics associated with effectiveness estimated using odds ratios. Meta-analysis was used to investigate pooled effectiveness. RESULTS We identified 201 eligible trials. Compared with China, trials from the USA/Canada (ratio of odds ratio, 1.89; 95% confidence interval, 1.45-2.45) and Europe/Australia/New Zealand (1.67; 1.29-2.18) had an 89% and 67% higher odds ratio, respectively, suggesting reduced effectiveness. The effectiveness was enhanced when the incidence of postoperative delirium increased (0.85; 0.79-0.92, per 10% increase). Trials with concerns related to deviations from intended interventions reported increased effectiveness compared with those at low risk (0.69; 0.53-0.90). Compared with usual care, certain interventions appeared to have reduced the incidence of postoperative delirium in low-risk trials with low-to-moderate certainty of evidence. However, these findings should be considered inconclusive because of challenges in grouping heterogeneous interventions, the limited number of eligible trials, the prevalence of small-scale studies, and potential publication bias. CONCLUSIONS The effectiveness of postoperative delirium trials varied based on the region of trial origin, the incidence of delirium, and the risk of bias. The limitations caution against drawing definitive conclusions from different bodies of evidence. These findings highlight the imperative need to improve the quality of research on a global scale. SYSTEMATIC REVIEW PROTOCOL PROSPERO (CRD42023413984).
Collapse
Affiliation(s)
- Lingzhong Meng
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA.
| | - Xu Zhao
- Department of Anesthesiology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yanhua Sun
- Department of Anesthesiology, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Shufen Cheng
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lin Bao
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - Kaiyun Fang
- Department of Anesthesiology, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Qiong Yu
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yueying Zheng
- Department of Anesthesiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jin Wang
- Department of Anesthesiology, The Second Affiliated Hospital, Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mengqiang Luo
- Department of Anesthesiology, Huashan Hospital, Fudan University, Shanghai, China
| | - David Gunderman
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Nikola Vuckovic
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Angad S Sidhu
- Indiana University School of Medicine, Indiana University, Indianapolis, IN, USA
| | - Jian Li
- Department of Anesthesiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Gang Li
- Department of Anesthesiology, Peking University Third Hospital, Beijing, China
| | - John W Wolfe
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Ziyue Liu
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, IN, USA
| | - David C Adams
- Department of Anesthesia, Indiana University School of Medicine, Indianapolis, IN, USA
| |
Collapse
|
5
|
Ni YX, Hu ZY, Wang RL, Huang Y, Jiang YY, Wang HY, Ruan SL, Zhou D, Chen Q, Jiang Y. Effect of the nurse-led Hospital Elder Life Program on delirium reduction among delirious patients with COVID-19: A randomized clinical trial. J Adv Nurs 2024. [PMID: 39140308 DOI: 10.1111/jan.16397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 07/26/2024] [Accepted: 08/02/2024] [Indexed: 08/15/2024]
Abstract
BACKGROUND Infectious diseases, such as COVID-19, are high-risk factors for delirium. However, the implementation of nonpharmacological interventions faces major challenges during an infectious disease pandemic. AIMS To evaluate the effect of the nurse-led Hospital Elder Life Program (NL-HELP) on delirium reduction among delirious patients with COVID-19. DESIGN A single-blind randomized clinical trial. METHODS This study recruited 122 delirious patients with COVID-19 from internal medicine wards at West China Hospital in China between January 30 and March 31, 2023. Participants were randomized to the NL-HELP group (n = 62) or the usual care group (n = 60). Patients in the intervention group received the NL-HELP protocol three times daily for 7 days. Patients in the control group received usual care. The primary outcome was the absence/presence of delirium during the intervention period measured by the 3-min Diagnostic Confusion Assessment Method. RESULTS Fewer patients remained delirious in the NL-HELP group than in the control group. There were significantly more delirium-free days in the NL-HELP group than in the usual care group. There were no statistically significant differences between the two groups in terms of delirium severity, length of hospital stay, delirium at 30 days after discharge, 30-day readmission, 30-day mortality, physical function or quality of life. CONCLUSIONS This study demonstrated that NL-HELP could reduce the presence of delirium in delirious patients. No effect was observed in terms of shortening the length of hospital stay, reducing 30-day mortality, or improving quality of life. IMPACT NL-HELP may be effective in reducing the presence of delirium in delirious patients. Further research is needed to determine whether the NL-HELP can improve patient outcomes (e.g. mortality and quality of life) in a larger study. PATIENT OR PUBLIC CONTRIBUTION Caregivers of delirious patients were invited to provide intervention strategies to prevent or abate delirium, including environmental management, orientation communications and identification of alert signs. TRIAL REGISTRATION This study was prospectively registered at the Chinese Clinical Trial Registry (https://www.chictr.org.cn/) Identifier: ChiCTR2300067874.
Collapse
Affiliation(s)
- Yun-Xia Ni
- Department of Cardiology, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Zi-Yi Hu
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Rui-Li Wang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yan Huang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yang-Yang Jiang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Hai-Yan Wang
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Shun-Li Ruan
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Dong Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Qian Chen
- Center of Gerontology and Geriatrics, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| | - Yan Jiang
- Department of Nursing, West China Hospital, Sichuan University/West China School of Nursing, Sichuan University, Chengdu, China
| |
Collapse
|
6
|
Wang J, Lu Y, Chen X, Wu Y. Effectiveness of nurse-led non-pharmacological interventions on outcomes of delirium in adults: A meta-analysis of randomized controlled trials. Worldviews Evid Based Nurs 2024. [PMID: 39086052 DOI: 10.1111/wvn.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 06/08/2024] [Accepted: 07/14/2024] [Indexed: 08/02/2024]
Abstract
BACKGROUND Delirium is a common complication among adults. It is essential to improve the outcomes of delirium. AIM To systematically synthesize the evidence on the effectiveness of the nurse-led non-pharmacological interventions on outcomes of delirium in adults. METHODS Electronic databases including CINAHL, Cochrane Library, MEDLINE, EMBASE, PubMed, Web of Science, PsycINFO, and Clinical Trial Registration were searched comprehensively by the authors. The authors reviewed the full text and assessed the risk of bias using the Cochrane Risk of Bias Tool 2.0. The meta-analysis was performed using RevMan and Stata software. The forest plots showed the overall effect of the included study and the I2 test was used to assess the degree of heterogeneity between studies. Random effects models were used to analyze studies with significant heterogeneity. RESULTS A total of 32 studies (10,122 participants) were included in the meta-analysis. Nurse-led non-pharmacological interventions resulted in a significantly lower incidence of delirium compared with the usual care/control group (risk ratio = 0.74, p < .001) and reduced mortality in the hospital compared with usual care (risk ratio = 0.81, p = .04). However, the implementation of nurse-led, non-pharmacological interventions had no significant effect on the duration, severity of delirium, or length of hospital stay. LINKING EVIDENCE TO ACTION Our findings suggest that the nurse-led, non-pharmacological strategy was effective in reducing the incidence of delirium and mortality in the hospital. Multicomponent interventions were the most effective strategy for reducing the incidence of delirium in adults.
Collapse
Affiliation(s)
- Jiamin Wang
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Yating Lu
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Xiaohong Chen
- School of Nursing, Beijing University of Chinese Medicine, Beijing, China
| | - Ying Wu
- School of Nursing, Capital Medical University, Beijing, China
| |
Collapse
|
7
|
Tuohy D, Boland P, Stark P, Cook L, Anderson T, Barry HE, Birch M, Brown-Wilson C, Cunningham E, McMahon J, Graham M, Curran GM, Mitchell G, Murphy J, Tierney A, Coffey A. Digital education about delirium for health care professional students: a mixed methods systematic review. BMC MEDICAL EDUCATION 2024; 24:762. [PMID: 39010110 PMCID: PMC11247797 DOI: 10.1186/s12909-024-05725-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 06/28/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Competence in delirium care begins with pre-registration education for health care professionals. Although a common complication for hospitalised patients, delirium is avoidable and reversible. Delirium requires early recognition in person-centred care. Students need to learn how to identify and effectively care for 'at risk' patients. AIM To identify and examine literature on how pre-registration health care professional students are prepared to recognise, assess, and deliver interventions to prevent delirium in practice, using digital/web based educational interventions. METHOD Mixed methods systematic review with narrative synthesis. A protocol was registered with PROSPERO. The review questions and search strategy were guided by the Population, Phenomena of Interest, Context (PICo) framework. The PRISMA framework guided the screening, data extraction and analysis. Database searches (MEDLINE, Web of Science, Embase, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO & Scopus) were undertaken in April 2023 for publications from 2012 to 2023. Covidence software [30] was used to extract and manage the data. Quality appraisal was guided by the Crowe Critical Appraisal Tool (CCAT) [31]. FINDINGS Ten papers were included: mixed methods (2), qualitative (1) and quantitative (7). Medical students were the most studied group (n = 5), followed by student nurses (n = 4) and mixed nursing and medical students (n = 1). Length of learning experience varied from 12 min virtual reality (VR) to a two-week 'geriatrics' elective. Learning was enhanced by player autonomy, engagement, safety, applicability, choices, multiple perspectives and moral reasoning opportunities. DISCUSSION Digital programmes should be visually appealing, interactive with opportunities for practice and timely appropriate feedback.
Collapse
Affiliation(s)
- Dympna Tuohy
- Department of Nursing and Midwifery, University of Limerick, Limerick, V94T9PX, Ireland.
| | - Pauline Boland
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Patrick Stark
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Lana Cook
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Tara Anderson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Heather E Barry
- Primary Care Research Group, School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast, BT9 7BL, Northern Ireland
| | - Matt Birch
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Christine Brown-Wilson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Emma Cunningham
- Centre for Public Health, Institute of Clinical Sciences, Queen's University Belfast, Block B, Belfast, BT12 6BA, Northern Ireland
| | - James McMahon
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Margaret Graham
- Department of Nursing and Midwifery, University of Limerick, Limerick, V94T9PX, Ireland
| | - Geoffrey M Curran
- Department of Nursing and Midwifery, University of Limerick, Limerick, V94T9PX, Ireland
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Gary Mitchell
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, BT9 7BL, Northern Ireland
| | - Jill Murphy
- Department of Nursing and Midwifery, University of Limerick, Limerick, V94T9PX, Ireland
| | - Audrey Tierney
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Alice Coffey
- Department of Nursing and Midwifery, University of Limerick, Limerick, V94T9PX, Ireland
| |
Collapse
|
8
|
Aldana EM, Pérez de Arriba N, Valverde JL, Aldecoa C, Fábregas N, Fernández-Candil JL. National survey on perioperative cognitive dysfunction. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024:S2341-1929(24)00122-7. [PMID: 38972351 DOI: 10.1016/j.redare.2024.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 11/29/2023] [Accepted: 02/15/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND Perioperative cognitive dysfunction (PCD) is a very prevalent clinical syndrome due to the progressive aging of the surgical population.The aim of our study is to evaluate the clinical practice of Spanish anesthesiologists surveyed regarding this entity. MATERIAL AND METHODS Prospective online survey conducted by the Neurosciences Section and distributed by SEDAR. RESULTS 544 responses were obtained, with a participation rate of 17%. 54.4% of respondents never make a preoperative assessment of cognitive impairment, only 7.5% always do it. 79.6% lack an intraoperative management protocol for the patient at risk of PCD. In the anesthetic planning, only 23.3% of the patients was kept in mind. Eighty-nine percent considered regional anesthesia with or without sedation preferable to general anesthesia for the prevention of PCD. 88.8% considered benzodiazepines to present a high risk of PCD. 71.7% considered that anesthetic depth monitoring could prevent postoperative cognitive deficit. Routine evaluation of postoperative delirium is low, only 14%. More than 80% recognize that PCD is underdiagnosed. CONCLUSIONS Among Spanish anesthesiologists surveyed, PCD is still a little known and underappreciated entity. It is necessary to raise awareness of the need to detect risk factors for PCD, as well as postoperative assessment and diagnosis. Therefore, the development of guidelines and protocols and the implementation of continuing education programs in which anesthesiologists should be key members of multidisciplinary teams in charge of perioperative care are suggested.
Collapse
Affiliation(s)
- E M Aldana
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain.
| | - N Pérez de Arriba
- Anestesiología y Reanimación, Hospital Universitario Central de Asturias, Oviedo, Spain
| | - J L Valverde
- Anestesiología y Reanimación, Hospital Vithas Xanit Internacional, Benalmádena, Málaga, Spain
| | - C Aldecoa
- Anestesiología y Reanimación, Hospital Universitario Rio Hortega, Valladolid, Spain
| | - N Fábregas
- Anestesiología y Reanimación, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain
| | | |
Collapse
|
9
|
Sadlonova M, Hansen N, Esselmann H, Celano CM, Derad C, Asendorf T, Chebbok M, Heinemann S, Wiesent A, Schmitz J, Bauer FE, Ehrentraut J, Kutschka I, Wiltfang J, Baraki H, von Arnim CAF. Preoperative Delirium Risk Screening in Patients Undergoing a Cardiac Surgery: Results from the Prospective Observational FINDERI Study. Am J Geriatr Psychiatry 2024; 32:835-851. [PMID: 38228452 DOI: 10.1016/j.jagp.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/18/2024]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common complication of cardiac surgery that is associated with higher morbidity, longer hospital stay, cognitive decline, and mortality. Preoperative assessments may help to identify patients´ POD risk. However, a standardized screening assessment for POD risk has not been established. DESIGN Prospective observational FINd DElirium RIsk factors (FINDERI) study. PARTICIPANTS Patients aged ≥50 years undergoing cardiac surgery. MEASUREMENTS The primary aim was to analyze the predictive value of the Delirium Risk Screening Questionnaire (DRSQ) prior to cardiac surgery. Secondary aims are to investigate cognitive, frailty, and geriatric assessments, and to use data-driven machine learning (ML) in predicting POD. Predictive properties were assessed using receiver operating characteristics analysis and multivariate approaches (regularized LASSO regression and decision trees). RESULTS We analyzed a data set of 504 patients (68.3 ± 8.2 years, 21.4% women) who underwent cardiac surgery. The incidence of POD was 21%. The preoperatively administered DRSQ showed an area under the curve (AUC) of 0.68 (95% CI 0.62, 0.73), and the predictive OR was 1.25 (95% CI 1.15, 1.35, p <0.001). Using a ML approach, a three-rule decision tree prediction model including DRSQ (score>7), Trail Making Test B (time>118), and Montreal Cognitive Assessment (score ≤ 22) was identified. The AUC of the three-rule decision tree on the training set was 0.69 (95% CI 0.63, 0.75) and 0.62 (95% CI 0.51, 0.73) on the validation set. CONCLUSION Both the DRSQ and the three-rule decision tree might be helpful in predicting POD risk before cardiac surgery.
Collapse
Affiliation(s)
- Monika Sadlonova
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Psychosomatic Medicine and Psychotherapy (MS,), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany; Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA.
| | - Niels Hansen
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Hermann Esselmann
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany
| | - Christopher M Celano
- Department of Psychiatry (MS, CMC), Massachusetts General Hospital, Boston, MA; Department of Psychiatry (CMC), Harvard Medical Schol, Boston, MA
| | - Carlotta Derad
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Thomas Asendorf
- Department of Medical Statistics (CD, TA), University of Göttingen Medical Center, Göttingen, Germany
| | - Mohammed Chebbok
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; Department of Cardiology and Pneumology (MC), University of Göttingen Medical Center, Göttingen, Germany
| | - Stephanie Heinemann
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Adriana Wiesent
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Jessica Schmitz
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Frederike E Bauer
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Julia Ehrentraut
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany
| | - Ingo Kutschka
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Jens Wiltfang
- Department of Psychiatry and Psychotherapy (NH, HE, JW), University of Göttingen Medical Center, Göttingen, Germany; German Center for Neurodegenerative Diseases (DZNE) (JW), Göttingen, Germany; Neurosciences and Signaling Group (JW), Institute of Biomedicine (iBiMED), Department of Medical Sciences, University of Aveiro, Aveiro, Portugal
| | - Hassina Baraki
- Department of Cardiovascular and Thoracic Surgery (MS, IK, HB), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| | - Christine A F von Arnim
- Department of Geriatrics (MS, MC, SH, AW, JS, FEB, JE, CAFA), University of Göttingen Medical Center, Göttingen, Germany; DZHK (German Center for Cardiovascular Research) (MS, IK, HB, CAFA), Göttingen, Germany
| |
Collapse
|
10
|
Yang X, Hu JH, Fan LP, Peng HP, Shi HJ, Zhuang MY, Ji FH, Peng K. Intraoperative dexmedetomidine on postoperative sleep disturbance in older patients undergoing major abdominal surgery: A randomized controlled trial protocol. Heliyon 2024; 10:e31668. [PMID: 38845907 PMCID: PMC11153091 DOI: 10.1016/j.heliyon.2024.e31668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/09/2024] Open
Abstract
Background Postoperative sleep disturbance (PSD) occurs frequently in patients who undergo major abdominal surgical procedures. Dexmedetomidine is a promising agent to improve the quality of sleep for surgical patients. We designed this trial to investigate the effects of two different doses of intraoperative dexmedetomidine on the occurrence of PSD in elderly patients who have major abdominal surgery. Methods In this randomized, double-blind, controlled trial, 210 elderly patients aged ≥65 years will be randomized, with an allocation ratio of 1:1:1, to two dexmedetomidine groups (intraoperative infusion of 0.3 or 0.6 μg/kg/h) and a normal saline placebo group. The primary endpoint is the occurrence of PSD on the first night after surgery, assessed using the Athens Insomnia Scale. The secondary endpoints are (1) the incidence of PSD during the 2nd, 3rd, 5th, 7th, and 30th nights postoperatively; (2) pain at rest and on movement at 24 and 48 h postoperatively, assessed using the Numerical Rating Scale; (3) the incidence of postoperative delirium during 0-7 days postoperatively or until hospital discharge, assessed using the 3-min Confusion Assessment Method; (4) depressive symptoms during 0-7 days postoperatively or until hospital discharge, assessed using the 15-items Geriatric Depression Scale; and (5) quality of recovery on postoperative days 1, 2, and 3, assessed using the 15-items Quality of Recovery Scale. Patients' sleep data will also be collected by Xiaomi Mi Band 7 for further analysis. Discussion The findings of this trial will provide clinical evidence for improving the quality of sleep among elderly patients undergoing major abdominal surgery. Ethics and dissemination This trial was approved by the Ethics Committee of the First Affiliated Hospital of Soochow University (No. 2023-160). The results will be published in a peer-reviewed journal. Trial registration Chinese Clinical Trial Registry (ChiCTR2300073163).
Collapse
Affiliation(s)
- Xiu Yang
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Jing-hui Hu
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Li-ping Fan
- Jintan Traditional Chinese Medicine Hospital, Changzhou, Jiangsu, China
| | - Hui-ping Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Hai-jing Shi
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Min-yuan Zhuang
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Fu-hai Ji
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| | - Ke Peng
- Department of Anesthesiology, First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Institute of Anesthesiology, Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
11
|
Deiner SG, Marcantonio ER, Trivedi S, Inouye SK, Travison TG, Schmitt EM, Hshieh T, Fong TG, Ngo LH, Vasunilashorn SM. Comparison of the frailty index and frailty phenotype and their associations with postoperative delirium incidence and severity. J Am Geriatr Soc 2024; 72:1781-1792. [PMID: 37964474 PMCID: PMC11090994 DOI: 10.1111/jgs.18677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/27/2023] [Accepted: 10/15/2023] [Indexed: 11/16/2023]
Abstract
BACKGROUND Recent studies have reported an association between presurgical frailty and postoperative delirium. However, it remains unclear whether the frailty-delirium relationship differs by measurement tool (e.g., frailty index vs. frailty phenotype) and whether frailty is associated with delirium, independent of preoperative cognition. METHODS We used the successful aging after elective surgery (SAGES) study, a prospective cohort of older adults age ≥70 undergoing major non-cardiac surgery (N = 505). Preoperative measurement of the modified mini-mental (3MS) test, frailty index and frailty phenotype were obtained. The confusion assessment method (CAM), supplemented by chart review, identified postoperative delirium. Delirium feature severity was measured by the sum of CAM-severity (CAM-S) scores. Generalized linear models were used to determine the relative risk of each frailty measure with delirium incidence and severity. Subsequent models adjusted for age, sex, surgery type, Charlson comorbidity index, and 3MS. RESULTS On average, patients were 76.7 years old (standard deviation 5.22), 58.8% of women. For the frailty index, the incidence of delirium was 14% in robust, 17% in prefrail, and 31% in frail patients (p < 0.001). For the frailty phenotype, delirium incidence was 13% in robust, 21% in prefrail, and 27% in frail patients (p = 0.016). Frailty index, but not phenotype, was independently associated with delirium after adjustment for comorbidities (relative risk [RR] 2.13, 95% confidence interval [CI] 1.23-3.70; RR 1.61, 95% CI 0.77-3.37, respectively). Both frailty measures were associated with delirium feature severity. After adjustment for preoperative cognition, only the frailty index was associated with delirium incidence; neither index nor phenotype was associated with delirium feature severity. CONCLUSION Both the frailty index and phenotype were associated with the development of postoperative delirium. The index showed stronger associations that remained significant after adjusting for baseline comorbidities and preoperative cognition. Measuring frailty prior to surgery can assist in identifying patients at risk for postoperative delirium.
Collapse
Affiliation(s)
- Stacie G Deiner
- Department of Anesthesiology, Dartmouth Health, Lebanon, New Hampshire, USA
| | - Edward R Marcantonio
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Shrunjal Trivedi
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Sharon K Inouye
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Thomas G Travison
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Eva M Schmitt
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
| | - Tammy Hshieh
- Harvard Medical School, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Division of Aging, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Tamara G Fong
- Harvard Medical School, Boston, Massachusetts, USA
- Aging Brain Center, Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Long H Ngo
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Biostatistics, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Sarinnapha M Vasunilashorn
- Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Epidemiology, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Detemble C, Heil J, Malkomes P, Faqar Uz Zaman F, Sliwinski S, Stickl F, Werneburg E, Faqar Uz Zaman F, Bechstein WO, Schnitzbauer AA. [Digital applications in prehabilitation before major visceral surgery procedures]. CHIRURGIE (HEIDELBERG, GERMANY) 2024; 95:436-442. [PMID: 38649473 DOI: 10.1007/s00104-024-02078-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/18/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Prehabilitation is of becoming of growing interest in the medical specialist societies, especially before major surgical procedures in older and frail patients. The body of evidence in steadily growing. OBJECTIVES Are there good digital solutions for a remote prehabilitation program at home? METHODS Narrative review of the evidence and current study activities in analogous and digital prehabilitation. RESULTS Prehabilitation is becoming increasingly more important in the optimal preparation of patients before major surgical procedures. With the help of tailored programs patients can be improved and the risk of complications can be significantly lowered. With an optimal selection, this is not associated with a deterioration of the prognosis for patients with cancer during the intervention lasting for 3-6 weeks. There is still a lack of results and good evidence from well-designed trials for digital solutions. CONCLUSION Prehabilitation can be safely implemented in the preparation of patients before major surgical procedures. Digital solutions are currently being developed and tested and could possibly increase the acceptance in the currently intensifying resource shortages.
Collapse
Affiliation(s)
- Charlotte Detemble
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Jan Heil
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Patrizia Malkomes
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Fatima Faqar Uz Zaman
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Svenja Sliwinski
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Franziska Stickl
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Elisabeth Werneburg
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Fatima Faqar Uz Zaman
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Andreas A Schnitzbauer
- Klinik für Allgemein‑, Viszeral‑, Transplantations- und Thoraxchirurgie, Universitätsklinikum Frankfurt am Main, Goethe Universität Frankfurt am Main, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
| |
Collapse
|
13
|
Weiss Y, Zarour S, Kiselevich Y, Abu Ghanim M, Hikry D, Sinai Brzezinski I, Zac L, Cohen B, Matot I. Preoperative cognitive impairment and postoperative delirium among Holocaust survivors who achieved longevity. J Am Geriatr Soc 2024; 72:1831-1838. [PMID: 38485466 DOI: 10.1111/jgs.18836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 01/28/2024] [Accepted: 02/05/2024] [Indexed: 06/19/2024]
Abstract
BACKGROUND Holocaust survivors (HS) experience higher rates of physiological and psychological morbidities, increasing their vulnerability to perioperative complications. Limited information exists regarding their perioperative neurocognitive disorders. This study aimed to assess the rates of preoperative cognitive impairment, postoperative delirium, and other complications among HS aged 75+ undergoing elective surgery. METHODS This is a single-center retrospective cohort study that analyzed prospectively collected data. All surgical patients born before 1945 who underwent elective noncardiac surgery at a tertiary hospital in Israel during 2020-2021 were included. The HS group was identified through the hospital's information system. Preoperative cognitive impairment was assessed using the Mini-Cog test. Postoperative delirium was defined as a combined outcome, which included a positive 4A's-Test (4AT) result during the postanesthesia care unit stay up to the second postoperative day, a positive 3-Minute Diagnostic Confusion Assessment Method (3D-CAM) test administered by the geriatric team, and identification through the medical records using the Chart-based Delirium Identification Instrument (CHART-DEL). We used multivariable regression to assess the risk factors for postoperative delirium. RESULTS Out of 1332 eligible patients, 422 (32%) were HS, while the others served as controls. Both groups had a similar rate of preoperative cognitive impairment (24%, p = 0.89) and postoperative delirium (16%, p = 0.95). HS exhibited a higher risk of the composite adverse events (24% vs. 20%, p = 0.05, aOR [95% CI] 1.3 [1.0-1.7]), driven mainly by falls during hospitalization (4% vs. 2%, p = 0.03, aOR 2.1 [1.1-4.1]). HS patients were more likely to be childless (33% vs. 11%, p = 0.001) and had higher rates of chronic antidepressant and benzodiazepine use. CONCLUSIONS HS achieving longevity do not face increased risks of preoperative cognitive impairment and postoperative delirium. However, special care is still warranted due to their elevated rate of other complications during hospitalization.
Collapse
Affiliation(s)
- Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Shiri Zarour
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossef Kiselevich
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Maher Abu Ghanim
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Daniel Hikry
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Isaac Sinai Brzezinski
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Lilach Zac
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
- Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio, USA
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| |
Collapse
|
14
|
Liu R, Liu N, Suo S, Yang Q, Deng Z, Fu W, Wang M. Incidence and risk factors of postoperative delirium following hepatic resection: a retrospective national inpatient sample database study. BMC Surg 2024; 24:151. [PMID: 38745220 PMCID: PMC11092011 DOI: 10.1186/s12893-024-02436-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 05/03/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common complication after major surgery and can cause a variety of adverse effects. However, no large-scale national database was used to assess the occurrence and factors associated with postoperative delirium (POD) following hepatic resection. METHODS Patients who underwent hepatic resection from 2015 to 2019 were screened using the International Classification of Diseases (ICD) 10th edition clinical modification code from the National Inpatient Sample (NIS) Database. Peri-operative factors associated with delirium were screened and underwent statistical analysis to identify independent predictors for delirium following hepatic resection. RESULTS A total of 80,070 patients underwent hepatic resection over a five-year period from 2015 to 2019. The overall occurrence of POD after hepatic resection was 1.46% (1039 cases), with a slight upward trend every year. The incidence of elective admission was 6.66% lower (88.60% vs. 81.94%) than that of patients without POD after hepatic resection and 2.34% (45.53% vs. 43.19%) higher than that of patients without POD in teaching hospitals (P < 0.001). In addition, POD patients were 6 years older (67 vs. 61 years) and comprised 9.27% (56.69% vs. 47.42%) more male patients (P < 0.001) compared to the unaffected population. In addition, the occurrence of POD was associated with longer hospitalization duration (13 vs. 5 days; P < 0.001), higher total cost ($1,481,89 vs. $683,90; P < 0.001), and higher in-hospital mortality (12.61% vs. 4.11%; P < 0.001). Multivariate logistic regression identified hepatic resection-independent risk factors for POD, including non-elective hospital admission, teaching hospital, older age, male sex, depression, fluid and electrolyte disorders, coagulopathy, other neurological disorders, psychoses, and weight loss. In addition, the POD after hepatic resection has been associated with sepsis, dementia, urinary retention, gastrointestinal complications, acute renal failure, pneumonia, continuous invasive mechanical ventilation, blood transfusion, respiratory failure, and wound dehiscence / non-healing. CONCLUSION Although the occurrence of POD after hepatic resection is relatively low, it is beneficial to investigate factors predisposing to POD to allow optimal care management and improve the outcomes of this patient population.
Collapse
Affiliation(s)
- Rui Liu
- Department of Anesthesiology, The Second Hospital of Lanzhou University, Lanzhou, Gansu, 730030, China
| | - Ningyuan Liu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Shanlian Suo
- Department of Anesthesiology, The Second Hospital of Lanzhou University, Lanzhou, Gansu, 730030, China
| | - Qinfeng Yang
- Division of Orthopaedic Surgery, Department of Orthopaedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, 510515, China
| | - Zhen Deng
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, Guangdong, 510515, China.
| | - Wei Fu
- Department of Anesthesiology, The Second Hospital of Lanzhou University, Lanzhou, Gansu, 730030, China.
| | - Min Wang
- Department of Anesthesiology, The Second Hospital of Lanzhou University, Lanzhou, Gansu, 730030, China.
| |
Collapse
|
15
|
Lay N, Foley P, Allen J. The effectiveness of preoperative delirium prevention in intermediate to high-risk older surgical patients: A systematic review. J Clin Nurs 2024; 33:1666-1683. [PMID: 38284498 DOI: 10.1111/jocn.17020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/16/2023] [Accepted: 01/10/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Few reviews have addressed delirium prevention among intermediate to high-risk older surgical patients. AIMS To map preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of developing delirium, assess outcomes and identify gaps in knowledge. DESIGN Systematic narrative review of randomised controlled trials reported following the PRISMA checklist. METHODS A systematic search was conducted of the literature published from 1990 to October 2022 in Medline, CINAHL and Ageline and of the grey literature in Google Scholar. Randomised controlled trials were retrieved that assessed the effectiveness of preoperative delirium prevention interventions for older surgical patients at intermediate to high risk of delirium. Data were extracted using a data extraction tool, and results were tabulated. Studies were assessed for bias using the Cochrane Collaboration Risk of Bias tool. RESULTS Twenty-one studies met the selection criteria including N = 5096 participants. Two studies tested cognitive training, two studies tested fascia iliaca compartment block and one study assessed femoral nerve block. Ten studies tested prophylactic medications including methylprednisolone. Five studies investigated geriatric assessment and management. One study assessed transcutaneous electrical acupoint stimulation. In the two studies testing fascia iliaca compartment block, there was a reduction in postoperative delirium for orthopaedic patients. Methylprednisolone reduced postoperative delirium in orthopaedic patients and in those undergoing gastrointestinal surgery. Results of all other interventions on the occurrence of postoperative delirium and additional outcomes including the severity and duration of delirium were inconclusive. CONCLUSIONS Despite the promising results for fascia iliaca compartment block and methylprednisolone, there is limited knowledge regarding evidence-based delirium prevention interventions. Most studies had small sample sizes indicating that the current evidence is exploratory. There is an urgent need for the funding and conduct of trials to test preventative interventions for older surgical patients at intermediate to high risk of developing delirium.
Collapse
Affiliation(s)
| | - Pieternella Foley
- School of Nursing and Midwifery, Monash University, Frankston, Victoria, Australia
| | - Jacqueline Allen
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
16
|
Benovic S, Ajlani AH, Leinert C, Fotteler M, Wolf D, Steger F, Kestler H, Dallmeier D, Denkinger M, Eschweiler GW, Thomas C, Kocar TD. Introducing a machine learning algorithm for delirium prediction-the Supporting SURgery with GEriatric Co-Management and AI project (SURGE-Ahead). Age Ageing 2024; 53:afae101. [PMID: 38776213 PMCID: PMC11110913 DOI: 10.1093/ageing/afae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 05/24/2024] Open
Abstract
INTRODUCTION Post-operative delirium (POD) is a common complication in older patients, with an incidence of 14-56%. To implement preventative procedures, it is necessary to identify patients at risk for POD. In the present study, we aimed to develop a machine learning (ML) model for POD prediction in older patients, in close cooperation with the PAWEL (patient safety, cost-effectiveness and quality of life in elective surgery) project. METHODS The model was trained on the PAWEL study's dataset of 878 patients (no intervention, age ≥ 70, 209 with POD). Presence of POD was determined by the Confusion Assessment Method and a chart review. We selected 15 features based on domain knowledge, ethical considerations and a recursive feature elimination. A logistic regression and a linear support vector machine (SVM) were trained, and evaluated using receiver operator characteristics (ROC). RESULTS The selected features were American Society of Anesthesiologists score, multimorbidity, cut-to-suture time, estimated glomerular filtration rate, polypharmacy, use of cardio-pulmonary bypass, the Montreal cognitive assessment subscores 'memory', 'orientation' and 'verbal fluency', pre-existing dementia, clinical frailty scale, age, recent falls, post-operative isolation and pre-operative benzodiazepines. The linear SVM performed best, with an ROC area under the curve of 0.82 [95% CI 0.78-0.85] in the training set, 0.81 [95% CI 0.71-0.88] in the test set and 0.76 [95% CI 0.71-0.79] in a cross-centre validation. CONCLUSION We present a clinically useful and explainable ML model for POD prediction. The model will be deployed in the Supporting SURgery with GEriatric Co-Management and AI project.
Collapse
Affiliation(s)
- Samuel Benovic
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Anna H Ajlani
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
- Department of Sociology with a Focus on Innovation and Digitalization, Institute of Sociology, Johannes Kepler University Linz, Linz, Austria
| | - Christoph Leinert
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Marina Fotteler
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
- DigiHealth Institute, Neu-Ulm University of Applied Sciences, Neu-Ulm, Germany
| | - Dennis Wolf
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Florian Steger
- Institute of the History, Philosophy and Ethics of Medicine, Ulm University, Ulm, Germany
| | - Hans Kestler
- Institute of Medical Systems Biology, Ulm University, Ulm, Germany
| | - Dhayana Dallmeier
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Department of Epidemiology, Boston University School of Public Health, Boston, USA
| | - Michael Denkinger
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| | - Gerhard W Eschweiler
- Geriatric Center, University Hospital Tübingen, Tubingen, Germany
- Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christine Thomas
- Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Thomas D Kocar
- Institute of Geriatric Research, Ulm University Medical Center, Ulm, Germany
- Agaplesion Bethesda Clinic Ulm, Ulm, Germany
| |
Collapse
|
17
|
Cook L, Coffey A, Brown Wilson C, Boland P, Stark P, Graham M, McMahon J, Tuohy D, Barry HE, Murphy J, Birch M, Tierney A, Anderson T, McCurtin A, Cunningham E, Curran GM, Mitchell G. Co-design and mixed methods evaluation of an interdisciplinary digital resource for undergraduate health profession students to improve the prevention, recognition, and management of delirium in Ireland: a study protocol. BMC MEDICAL EDUCATION 2024; 24:475. [PMID: 38689311 PMCID: PMC11061903 DOI: 10.1186/s12909-024-05468-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 04/25/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Delirium is a common symptom of acute illness which is potentially avoidable with early recognition and intervention. Despite being a growing concern globally, delirium remains underdiagnosed and poorly reported, with limited understanding of effective delirium education for undergraduate health profession students. Digital resources could be an effective approach to improving professional knowledge of delirium, but studies utilising these with more than one profession are limited, and no evidence-based, interdisciplinary, digital delirium education resources are reported. This study aims to co-design and evaluate a digital resource for undergraduate health profession students across the island of Ireland to improve their ability to prevent, recognise, and manage delirium alongside interdisciplinary colleagues. METHODS Utilising a logic model, three workstreams have been identified. Workstream 1 will comprise three phases: (1) a systematic review identifying the format, methods, and content of existing digital delirium education interventions for health profession students, and their effect on knowledge, self-efficacy, and behavioural change; (2) focus groups with health profession students to determine awareness and experiences of delirium care; and (3) a Delphi survey informed by findings from the systematic review, focus groups, and input from the research team and expert reference group to identify resource priorities. Workstream 2 will involve the co-design of the digital resource through workshops (n = 4) with key stakeholders, including health profession students, professionals, and individuals with lived experience of delirium. Lastly, Workstream 3 will involve a mixed methods evaluation of the digital resource. Outcomes include changes to delirium knowledge and self-efficacy towards delirium care, and health profession students experience of using the resource. DISCUSSION Given the dearth of interdisciplinary educational resources on delirium for health profession students, a co-designed, interprofessional, digital education resource will be well-positioned to shape undergraduate delirium education. This research may enhance delirium education and the self-efficacy of future health professionals in providing delirium care, thereby improving practice and patients' experiences and outcomes. TRIAL REGISTRATION Not applicable.
Collapse
Affiliation(s)
- Lana Cook
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Alice Coffey
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | | | - Pauline Boland
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Patrick Stark
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Margaret Graham
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - James McMahon
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Dympna Tuohy
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | | | - Jill Murphy
- Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
| | - Matt Birch
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Audrey Tierney
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Tara Anderson
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Arlene McCurtin
- School of Allied Health, University of Limerick, Limerick, Ireland
| | - Emma Cunningham
- School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | - Geoffrey M Curran
- Center for Implementation Research, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Gary Mitchell
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK.
| |
Collapse
|
18
|
Lauffer-Vogt SU, Hediger H, Lauener SK, Schubert M. [The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital]. Pflege 2024; 37:89-97. [PMID: 37997948 DOI: 10.1024/1012-5302/a000965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
The use of the DOS and Delirium Prevalence: a quantitative longitudinal study at a Swiss-German central hospital Abstract: Background: With a prevalence of 12-64%, delirium is a common complication in acute care, associated with negative outcomes such as increased mortality and prolonged length of stay. Many hospitals have guidelines to improve the delirium management. The Delirium Observation Screening Scale (DOS) Score is collected in the study hospital from all patients ≥ 70 years at each shift for at least 3 days. Delirium is diagnosed by a physician and coded according to ICD-10. Purpose: Evaluation of the delirium screening with the DOS according to internal guideline in terms of number of DOS assessments performed, prevalence of delirium (DOS score ≥ 3 points, CD-10 code delirium). Method: This retrospective quantitative single-centre longitudinal study used 2017 and 2018 data of 10046 cases. Statistical analysis methods were used to analyse prevalence of delirium and subgroup comparisons. Results: At least one DOS score was documented in 92% of cases aged ≥ 70-years (n = 5038). DOS implementation varied between 60% in the early, 49% in the late and 38% in the night shift. The prevalence of delirium was 12% according to DOS score ≥ 3 and 4% according to physician diagnosis of a delirium. Cases with a DOS score ≥ 3 were significantly older, more often female, had more comorbidities and were depressed. Conclusions: DOS is performed in most patients when indicated. The DOS implementation frequency varied depending on the shift.
Collapse
Affiliation(s)
- Stefan Urs Lauffer-Vogt
- Klinik für Plastische Chirurgie und Handchirurgie, Klinik für Traumatologie, Universitätsspital Zürich, Schweiz
| | - Hannele Hediger
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| | - Susanne Knüppel Lauener
- Abteilung für Praxisentwicklung und Forschung Pflege/MTT, Medizinische Direktion, Universitätsspital Basel, Schweiz
| | - Maria Schubert
- Institut für Pflege, Departement Gesundheit, Zürcher Hochschule für Angewandte Wissenschaften, Winterthur, Schweiz
| |
Collapse
|
19
|
Tang J, Tang Y, Lin P, Zheng J, Li Z, Zhang Y. Integrative analysis of circRNA networks in postoperative cognitive dysfunction. Int J Neurosci 2024:1-33. [PMID: 38261527 DOI: 10.1080/00207454.2024.2309473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 01/13/2024] [Indexed: 01/25/2024]
Abstract
OBJECTIVE In the quest to decipher the molecular intricacies of Postoperative Cognitive Dysfunction (POCD), this study focused on circular RNA (circRNA) and their regulatory networks. MATERIALS AND METHODS Analyzing the Gene Expression Omnibus Series (GSE) 147277 dataset, we pinpointed 10 differentially expressed circRNAs linked to POCD. RESULTS The ensuing competing endogenous RNA (ceRNA) network, featuring pivotal players like Homo sapiens(hsa)_circ_0003424 and hsa-miR-193b-5p, provided a comprehensive understanding of the molecular players at play in POCD. CONCLUSION Additionally, the Protein-Protein Interaction (PPI) network spotlighted 10 core Hub genes, including phosphatase and tensin homolog (PTEN) and signal transducer and activator of transcription 3(STAT3), shedding light on potential therapeutic targets.
Collapse
Affiliation(s)
- Jian Tang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| | - Yanhong Tang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| | - Peimin Lin
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| | - Jie Zheng
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| | - Zhengfen Li
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| | - Ying Zhang
- Department of Anesthesiology, The Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, P. R. China
| |
Collapse
|
20
|
Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
Collapse
Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Frost SA, Brennan K, Sanchez D, Lynch J, Hedges S, Hou YC, El Sayfe M, Shunker SA, Bogdanovski T, Hunt L, Alexandrou E, Rolls K, Chroinin DN, Aneman A. Frailty in the prediction of delirium in the intensive care unit: A secondary analysis of the Deli study. Acta Anaesthesiol Scand 2024; 68:214-225. [PMID: 37903745 DOI: 10.1111/aas.14343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND Delirium is an acute disorder of attention and cognition with an incidence of up to 70% in the adult intensive care setting. Due to the association with significantly increased morbidity and mortality, it is important to identify who is at the greatest risk of an acute episode of delirium while being cared for in the intensive care. The objective of this study was to determine the ability of the cumulative deficit frailty index and clinical frailty scale to predict an acute episode of delirium among adults admitted to the intensive care. METHODS This study is a secondary analysis of the Deli intervention study, a hybrid stepped-wedge cluster randomized controlled trial to assess the effectiveness of a nurse-led intervention to reduce the incidence and duration of delirium among adults admitted to the four adult intensive care units in the south-west of Sydney, Australia. Important predictors of delirium were identified using a bootstrap approach and the absolute risks, based on the cumulative deficit frailty index and the clinical frailty scale are presented. RESULTS During the 10-mth data collection period (May 2019 and February 2020) 2566 patients were included in the study. Both the cumulative deficit frailty index and the clinical frailty scale on admission, plus age, sex, and APACHE III (AP III) score were able to discriminate between patients who did and did not experience an acute episode of delirium while in the intensive care, with AUC of 0.701 and 0.703 (moderate discriminatory ability), respectively. The addition of a frailty index to a prediction model based on age, sex, and APACHE III score, resulted in net reclassified of risk. Nomograms to individualize the absolute risk of delirium using these predictors are also presented. CONCLUSION We have been able to show that both the cumulative deficits frailty index and clinical frailty scale predict an acute episode of delirium among adults admitted to intensive care.
Collapse
Affiliation(s)
- Steven A Frost
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- South Western Sydney Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Sydney, Australia
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Kathleen Brennan
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
- Department of Intensive Care, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - David Sanchez
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Campbelltown-Camden Hospital, Sydney, Australia
| | - Joan Lynch
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Sonja Hedges
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Bankstown-Lidcombe Hospital, Sydney, Australia
| | - Yu Chin Hou
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Masar El Sayfe
- Department of Intensive Care, Fairfield Hospital, Sydney, Australia
| | | | - Tony Bogdanovski
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
| | - Leanne Hunt
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
| | - Evan Alexandrou
- Critical Care Research in Collaboration and Evidence Translation, Sydney, Australia
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- School of Nursing, Western Sydney University, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Kaye Rolls
- School of Nursing, University of Wollongong, Wollongong, Australia
| | - Danielle Ni Chroinin
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Anders Aneman
- Department of Intensive Care, Liverpool Hospital, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| |
Collapse
|
22
|
Chen Z, Hao Q, Sun R, Zhang Y, Fu H, Liu S, Luo C, Chen H, Zhang Y. Predictive value of the geriatric nutrition risk index for postoperative delirium in elderly patients undergoing cardiac surgery. CNS Neurosci Ther 2024; 30:e14343. [PMID: 37408469 PMCID: PMC10848042 DOI: 10.1111/cns.14343] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 05/07/2023] [Accepted: 06/24/2023] [Indexed: 07/07/2023] Open
Abstract
AIMS The aims of the study were to determine the relationship between preoperative geriatric nutritional risk index (GNRI) and the occurrence of postoperative delirium (POD) in elderly patients after cardiac surgery and to evaluate the additive value of GNRI for predicting POD. METHODS The data were extracted from the Multiparameter Intelligent Monitoring in Intensive Care (MIMIC-IV) database. Patients who underwent cardiac surgery and were aged 65 or older were included. The relationship between preoperative GNRI and POD was investigated using logistic regression. We determined the added predictive value of preoperative GNRI for POD by measuring the changes in the area under the receiver operating characteristic curve (AUC) and calculating the net reclassification improvement (NRI) and integrated discrimination improvement (IDI). RESULTS A total of 4286 patients were included in the study, and 659 (16.1%) developed POD. Patients with POD had significantly lower GNRI scores than patients without POD (median 111.1 vs. 113.4, p < 0.001). Malnourished patients (GNRI ≤ 98) had a significantly higher risk of POD (odds ratio, 1.83, 90% CI, 1.42-2.34, p < 0.001) than those without malnutrition (GNRI > 98). This correlation remains after adjusting for confounding variables. The addition of GNRI to the multivariable models slightly but not significantly increases the AUCs (all p > 0.05). Incorporating GNRI increases NRIs in some models and IDIs in all models (all p < 0.05). CONCLUSIONS Our results showed a negative association between preoperative GNRI and POD in elderly patients undergoing cardiac surgery. The addition of GNRI to POD prediction models may improve their predictive accuracy. However, these findings were based on a single-center cohort and will need to be validated in future studies involving multiple centers.
Collapse
Affiliation(s)
- Zhiqiang Chen
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Quanshui Hao
- Department of AnesthesiologyHuanggang Central Hospital of Yangtze UniversityHuanggangChina
| | - Rao Sun
- Department of Anesthesiology, Tongji Hospital, Tongji Medical CollegeHuazhong University of Science and TechnologyWuhanChina
| | - Yanjing Zhang
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Hui Fu
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Shile Liu
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Chenglei Luo
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Hanwen Chen
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| | - Yiwen Zhang
- Department of Anesthesiology, Shunde HospitalSouthern Medical University (The First People's Hospital of Shunde)FoshanChina
| |
Collapse
|
23
|
Callan KT, Donnelly M, Lung B, McLellan M, DiGiovanni R, McMaster W, Yang S, Stitzlein R. Risk factors for postoperative delirium in orthopaedic hip surgery patients: a database review. BMC Musculoskelet Disord 2024; 25:71. [PMID: 38233831 PMCID: PMC10792907 DOI: 10.1186/s12891-024-07174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/05/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Postoperative delirium is a common problem affecting admitted patients that decreases patient satisfaction and increases the cost and complexity of care. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to compare rates and risk factors of postoperative delirium for total hip arthroplasty (THA) and hemiarthroplasty patients indicated for osteoarthritis or proximal femur fracture. METHODS The 2021 NSQIP database was queried for patients using Current Procedural Terminology (CPT) codes for THA and hemiarthroplasty and ICD-10 codes for osteoarthritis or proximal femur fracture. Demographic, past medical history, preoperative labs, and functional status data were recorded. Procedural data were also collected. Finally, postoperative outcomes and complications were reviewed. RESULTS Overall, 16% of patients had postoperative delirium. Delirium patients were older on average (82.4 years vs. 80.7 years, p < 0.001), had a lower BMI (19.5 vs. 24.8, p < 0.001), were more likely to have a history of dementia (54.6% vs. 13.6%, p < 0.001), were less likely to have an independent functional status (p < 0.001) or live alone (p < 0.001), and were more likely to have sustained a recent fall (p < 0.001). Delirium patients were more likely to be hyponatremic or hypernatremic (p = 0.002), anemic (p < 0.001), and severely dehydrated (p < 0.001), among other lab abnormalities. Delirium patients were also more likely to experience additional postoperative complications, including pneumonia, pulmonary embolism, urinary tract infection, stroke, cardiac arrest, sepsis, and unplanned reoperation and readmission after discharge (all p < 0.05). CONCLUSIONS In this study, factors associated with postoperative delirium in patients undergoing hemiarthroplasty and THA were identified, including older age, lower BMI, certain medical conditions, decreased functional status, certain lab abnormalities, and postoperative complications. These findings can be used by clinicians to better inform care and to determine when orthopaedic joint replacement patients may be at an increased risk for postoperative delirium.
Collapse
Affiliation(s)
- Kylie T Callan
- University of California Irvine School of Medicine, Irvine, CA, USA.
| | - Megan Donnelly
- New York University Langone Medical Center, New York, NY, USA
| | - Brandon Lung
- University of California Irvine Health, Orange, CA, USA
| | | | | | | | - Steven Yang
- University of California Irvine Health, Orange, CA, USA
| | | |
Collapse
|
24
|
Greenberg B, Jiang S, Nadler A. Postoperative protocols for older adults undergoing emergency surgery: a scoping review. Can J Surg 2024; 67:E149-E157. [PMID: 38575179 PMCID: PMC11001382 DOI: 10.1503/cjs.011323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND As the population of older adults expands, it is becoming increasingly crucial to develop perioperative protocols to meet their physiologic, functional, and cognitive demands after emergency surgery. We sought to identify protocols that improve the disposition, length of stay, and overall health outcomes of older adults undergoing emergency intracavitary, noncardiac surgery. METHODS Embase, Cochrane, and MEDLINE databases were searched, and results were deduplicated and uploaded to Covidence. We reviewed studies for postoperative interventions that reduced delirium, maintained functional status, and reduced length of stay in older patients undergoing emergency surgery. We included studies involving patients aged 65 years and older undergoing emergency intracavitary, noncardiac surgeries. Abstracts and full texts were reviewed by 2 reviewers. Data were extracted on the postoperative interventions used and the resulting patient outcomes. RESULTS We included 6 studies, which involved patients undergoing emergency general, urology, and vascular surgery. Interventions included a multidisciplinary approach, early involvement of a geriatrician or hospitalist, targeted geriatric-led ward rounds, unique postoperative order sets, and volunteer-driven activities. Standard care included early removal of lines, early mobility, optimal hydration, and medication review. These interventions were associated with decreased length of stay, decreased postoperative complications, and increased likelihood of disposition to home and previous functional status. Frailty was correlated with worse outcomes. CONCLUSION Through multidisciplinary interventions, a successful postoperative protocol for older patients undergoing emergency surgery is helpful for improving patient outcomes. The implications of these findings will help guide our own quality-improvement initiative to improve these outcomes in this patient population at our institution.
Collapse
Affiliation(s)
- Brianna Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Stephanie Jiang
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| | - Ashlie Nadler
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Jiang); and the Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nadler)
| |
Collapse
|
25
|
Wang Y, Zhu H, Xu F, Ding Y, Zhao S, Chen X. The effect of anesthetic depth on postoperative delirium in older adults: a systematic review and meta-analysis. BMC Geriatr 2023; 23:719. [PMID: 37932677 PMCID: PMC10629190 DOI: 10.1186/s12877-023-04432-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 10/27/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is an important complication for older patients and recent randomised controlled trials have showed a conflicting result of the effect of deep and light anesthesia. METHODS We included randomised controlled trials including older adults that evaluated the effect of anesthetic depth on postoperative delirium from PubMed, Embase, Web of Science and Cochrane Library. We considered deep anesthesia as observer's assessment of the alertness/ sedation scale (OAA/S) of 0-2 or targeted bispectral (BIS) < 45 and the light anesthesia was considered OAA/S 3-5 or targeted BIS > 50. The primary outcome was incidence of POD within 7 days after surgery. And the secondary outcomes were mortality and cognitive function 3 months or more after surgery. The quality of evidence was assessed via the grading of recommendations assessment, development, and evaluation approach. RESULTS We included 6 studies represented 7736 patients aged 60 years and older. We observed that the deep anesthesia would not increase incidence of POD when compared with the light anesthesia when 4 related studies were pooled (OR, 1.40; 95% CI, 0.63-3.08, P = 0.41, I2 = 82%, low certainty). And no significant was found in mortality (OR, 1.12; 95% CI, 0.93-1.35, P = 0.23, I2 = 0%, high certainty) and cognitive function (OR, 1.13; 95% CI, 0.67-1.91, P = 0.64, I2 = 13%, high certainty) 3 months or more after surgery between deep anesthesia and light anesthesia. CONCLUSIONS Low-quality evidence suggests that light general anesthesia was not associated with lower POD incidence than deep general anesthesia. And High-quality evidence showed that anesthetic depth did not affect the long-term mortality and cognitive function. SYSTEMATIC REVIEW REGISTRATION CRD42022300829 (PROSPERO).
Collapse
Affiliation(s)
- Yafeng Wang
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Hongyu Zhu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
- Department of Anesthesiology, Linhe District People's Hospital, Bayannur City, 015000, China
| | - Feng Xu
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Yuanyuan Ding
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Shuai Zhao
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China
| | - Xiangdong Chen
- Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Institute of Anesthesia and Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
- Key Laboratory of Anesthesiology and Resuscitation, Huazhong University of Science and Technology, Ministry of Education, Wuhan, China.
| |
Collapse
|
26
|
Ketelaers SHJ, Jacobs A, van der Linden CMJ, Nieuwenhuijzen GAP, Tolenaar JL, Rutten HJT, Burger JWA, Bloemen JG. An evaluation of postoperative outcomes and treatment changes after frailty screening and geriatric assessment and management in a cohort of older patients with colorectal cancer. J Geriatr Oncol 2023; 14:101647. [PMID: 37862736 DOI: 10.1016/j.jgo.2023.101647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 07/23/2023] [Accepted: 10/10/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Adequate patient selection is crucial within the treatment of older patients with colorectal cancer (CRC). While previous studies report increased morbidity and mortality in older patients screened positive for frailty, improvements in the perioperative care and postoperative outcomes have raised the question of whether older patients screened positive for frailty still face worse outcomes. This study aimed to investigate the postoperative outcomes of older patients with CRC screened positive for frailty, and to evaluate changes in treatment after frailty screening and geriatric assessment. MATERIALS AND METHODS Patients ≥70 years with primary CRC who underwent frailty screening between 1 January 2019 and 31 October 2021 were included. Frailty screening was performed by the Geriatric-8 (G8) screening tool. If the G8 indicated frailty (G8 ≤ 14), patients were referred for a comprehensive geriatric assessment (CGA). Postoperative outcomes and changes in treatment based on frailty screening and CGA were evaluated. RESULTS A total of 170 patients were included, of whom 74 (43.5%) screened positive for frailty (G8 ≤ 14). Based on the CGA, the initially proposed treatment plan was altered to a less intensive regimen in five (8.9%) patients, and to a more intensive regimen in one (1.8%) patient. Surgery was performed in 87.8% of patients with G8 ≤ 14 and 96.9% of patients with G8 > 14 (p = 0.03). Overall postoperative complications were similar between patients with G8 ≤ 14 and G8 > 14 (46.2% vs. 47.3%, p = 0.89). Postoperative delirium was observed in 7.7% of patients with G8 ≤ 14 and 1.1% of patients with G8 > 14 (p = 0.08). No differences in 30-day mortality (1.1% vs. 1.5%, p > 0.99) or one-year and two-year survival rates were observed (log rank, p = 0.26). DISCUSSION Although patients screened positive for frailty underwent CRC surgery less often, those considered eligible for surgery can safely undergo CRC resection within current clinical care pathways, without increased morbidity and mortality. Efforts to optimise perioperative care and minimise the risk of postoperative complications, in particular delirium, seem warranted. A multidisciplinary onco-geriatric pathway may support tailored decision-making in patients at risk of frailty.
Collapse
Affiliation(s)
- Stijn H J Ketelaers
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands.
| | - Anne Jacobs
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Carolien M J van der Linden
- Department of Gerontology and Geriatrics, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | | | - Jip L Tolenaar
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Harm J T Rutten
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands; Department of GROW, School for Oncology & Reproduction, Maastricht University, Maastricht, the Netherlands
| | - Jacobus W A Burger
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital, PO Box 1350, 5602 ZA Eindhoven, the Netherlands
| |
Collapse
|
27
|
Weidner E, Hancke L, Nydahl P, Spies C, Lütz A. [Non-pharmacological Management of Postoperative Delirium]. Anasthesiol Intensivmed Notfallmed Schmerzther 2023; 58:494-512. [PMID: 37725991 DOI: 10.1055/a-2065-3764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/21/2023]
Abstract
Postoperative delirium is common especially in the elderly and is associated with high rates of morbidity and mortality. Non-pharmacological multicomponent interventions are effective in reducing the incidence and to a degree the duration of postoperative delirium and are recommended in international guidelines on postoperative delirium as first line intervention for management of delirium. Non-pharmacological management of postoperative delirium consists of strategies for risk stratification, risk reduction by non-pharmacological bundle interventions, early recognition of delirium by screening protocols and immediate therapy of underlying causes of delirium and continuation of non-pharmacological bundles. Non-pharmacological bundle interventions address common perioperative risk factors. Bundles comprise strategies for oxygenation, mobilization, hydration and nutrition, sensory and cognitive stimulation, reorientation, modifications of environmental factors such as design aspects and noise reduction, adequate analgesia, management of agitation and anxiety, protecting circadian rhythms for example by adequate light exposure during daytime, family involvement and timely reduction of unnecessary catheters and anticholinergic drugs. The article aims at providing an overview of non-pharmacological management of postoperative delirium in the hospital.
Collapse
|
28
|
Sadlonova M, von Arnim CAF. [Update on the diagnosis and treatment of delirium]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:855-863. [PMID: 37540259 DOI: 10.1007/s00108-023-01561-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/19/2023] [Indexed: 08/05/2023]
Abstract
Delirium is an acute confusional state with typically fluctuating disturbances of attention, cognition, and qualitative awareness. Its incidence depends on the patient group. In the development of delirium, predisposing factors such as age, frailty, multimorbidity, surgical interventions, and pre-existing dementia are of high clinical relevance. The diagnosis of delirium should be based on symptoms and validated screening methods (e.g., Confusion Assessment Method). As delirium is a direct physiological consequence of a medical condition, the potential underlying cause(s) should be diagnosed. Prevention and therapy are primarily multimodal, non-pharmacological treatments such as reorientation, early mobilization, and sleep improvement. If symptomatic pharmacological treatment is necessary (e.g., due to delirium-related agitation), careful drug selection should be made depending on the patient population and symptoms.
Collapse
Affiliation(s)
- Monika Sadlonova
- Klinik für Psychosomatische Medizin und Psychotherapie, Herzzentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Klinik für Herz‑, Thorax und Gefäßchirurgie, Herzzentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland
- Klinik für Geriatrie, Herzzentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Göttingen, Herzzentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland
| | - Christine A F von Arnim
- Klinik für Geriatrie, Herzzentrum, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37077, Göttingen, Deutschland.
- Deutsches Zentrum für Herz-Kreislauf-Forschung, Standort Göttingen, Herzzentrum, Universitätsmedizin Göttingen, Göttingen, Deutschland.
| |
Collapse
|
29
|
Scott MJ, Aggarwal G, Aitken RJ, Anderson ID, Balfour A, Foss NB, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Johnston C, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Sharoky C, Urman RD, Wick E, Wu CL, Young-Fadok T, Peden CJ. Consensus Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS ®) Society Recommendations Part 2-Emergency Laparotomy: Intra- and Postoperative Care. World J Surg 2023; 47:1850-1880. [PMID: 37277507 PMCID: PMC10241558 DOI: 10.1007/s00268-023-07020-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/28/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND This is Part 2 of the first consensus guidelines for optimal care of patients undergoing emergency laparotomy (EL) using an Enhanced Recovery After Surgery (ERAS) approach. This paper addresses intra- and postoperative aspects of care. METHODS Experts in aspects of management of high-risk and emergency general surgical patients were invited to contribute by the International ERAS® Society. PubMed, Cochrane, Embase, and Medline database searches were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized clinical trials, systematic reviews, meta-analyses, and large cohort studies and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on elective patients when appropriate. A modified Delphi method was used to validate final recommendations. Some ERAS® components covered in other guideline papers are outlined only briefly, with the bulk of the text focusing on key areas pertaining specifically to EL. RESULTS Twenty-three components of intraoperative and postoperative care were defined. Consensus was reached after three rounds of a modified Delphi Process. CONCLUSIONS These guidelines are based on best available evidence for an ERAS® approach to patients undergoing EL. These guidelines are not exhaustive but pull together evidence on important components of care for this high-risk patient population. As much of the evidence is extrapolated from elective surgery or emergency general surgery (not specifically laparotomy), many of the components need further evaluation in future studies.
Collapse
Affiliation(s)
- Michael J. Scott
- Department of Anesthesiology and Critical Care Medicine, Leonard Davis Institute for Health Economics, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
- University College London, London, UK
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | - Angie Balfour
- Western General Hospital, NHS Lothian, Edinburgh, EH4 2XU Scotland
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620 Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital Huddinge, Hälsovägen 3. B85, 141 86 Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Carolyn Johnston
- Department of Anesthesia, St George’s Hospital, Tooting, London, UK
| | - Jeniffer S. Kim
- Department of Research and Evaluation, Kaiser Permanente Research, Pasadena, CA 9110 USA
| | - Nicholas P. Lees
- Department of General and Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Faculty of Medicine and Health, School of Health and Medical Sciences, Department of Surgery, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, 701 85 Orebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Catherine Sharoky
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Richard D. Urman
- Department of Anesthesiology, The Ohio State University and Wexner Medical Center, 410 West 10Th Ave, Columbus, OH 43210 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, Department of Anesthesiology-Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 e. Mayo Blvd., Phoenix, AZ 85054 USA
| | - Carol J. Peden
- Department of Anesthesiology Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104 USA
| |
Collapse
|
30
|
Tsai CY, Liu KH, Lai CC, Hsu JT, Hsueh SW, Hung CY, Yeh KY, Hung YS, Lin YC, Chou WC. Association of preoperative frailty and postoperative delirium in older cancer patients undergoing elective abdominal surgery: A prospective observational study in Taiwan. Biomed J 2023; 46:100557. [PMID: 35985478 PMCID: PMC10345226 DOI: 10.1016/j.bj.2022.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 08/09/2022] [Accepted: 08/09/2022] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common surgical complication in elderly patients. As frailty is a relatively novel concept, its clinical significance for POD has seldom been examined. This study aimed to investigate the association between frailty and POD in aged cancer patients undergoing elective abdominal surgery in Taiwan. METHODS We prospectively enrolled 345 consecutive patients aged ≥65 years with newly diagnosed cancer who underwent elective abdominal surgery between 2016 and 2018. Frailty assessment was performed using the Comprehensive Geriatric Assessment (CGA). POD was assessed daily using the Confusion Assessment Method from postoperative day 1 until discharge. Patients were allocated into fit and frail groups. RESULTS POD occurred in 19 (5.5%) of 345 patients. POD incidence was 1.6%, 3.1%, 4.8%, 11.5%, and 10.0% in patients with 0, 1, 2, 3, and 4+ frail conditions, respectively, which presented a positive linear correlation among patients with an increased number of frail conditions and POD incidence. Based on CGA, 159 (46.1%) and 186 (53.9%) patients were allocated to fit and frail groups, respectively. POD incidence was 2.5% and 8.1% for the fit and frail groups, respectively. Frailty status was an independent risk factor for POD occurrence in multivariate analysis. CONCLUSION Our study identified frailty as an independent risk factor for POD in aged Taiwanese cancer patients undergoing elective abdominal surgery. Given the high prevalence of frailty among older cancer patients, preoperative assessment is important to identify high risk of POD and to improve the quality of postoperative care.
Collapse
Affiliation(s)
- Chun-Yi Tsai
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Keng-Hao Liu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Chou Lai
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Colon and Rectal Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Jun-Te Hsu
- Department of General Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Shun-Wen Hsueh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Chia-Yen Hung
- Division of Hematology and Oncology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Kun-Yun Yeh
- Department of Oncology, Chang Gung Memorial Hospital at Keelung, Keelung, Taiwan
| | - Yu-Shin Hung
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Yung-Chang Lin
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Chi Chou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Hematology and Oncology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
| |
Collapse
|
31
|
Gong XY, Hou DJ, Yang J, He JL, Cai MJ, Wang W, Lu XY, Gao J. Incidence of delirium after non-cardiac surgery in the Chinese elderly population: a systematic review and meta-analysis. Front Aging Neurosci 2023; 15:1188967. [PMID: 37455941 PMCID: PMC10346854 DOI: 10.3389/fnagi.2023.1188967] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Accepted: 06/12/2023] [Indexed: 07/18/2023] Open
Abstract
Background POD places a heavy burden on the healthcare system as the number of elderly people undergoing surgery is increasing annually because of the aging population. As a large country with a severely aging population, China's elderly population has reached 267 million. There has been no summary analysis of the pooled incidence of POD in the elderly Chinese population. Methods Systematic search databases included PubMed, Web of Science, EMBASE, Cochrane Library Databases, China Knowledge Resource Integrated Database (CNKI), Chinese Biomedical Database (CBM), WanFang Database, and Chinese Science and Technology Periodicals (VIP). The retrieval time ranged from the database's establishment to February 8, 2023. The pooled incidence of delirium after non-cardiac surgery was calculated using a random effects model. Meta-regression, subgroup, and sensitivity analyses were used to explore the source of heterogeneity. Results A total of 52 studies met the inclusion criteria, involving 18,410 participants. The pooled incidence of delirium after non-cardiac surgery in the elderly Chinese population was 18.6% (95% CI: 16.4-20.8%). The meta-regression results revealed anesthesia method and year of publication as a source of heterogeneity. In the subgroup analysis, the gender subgroup revealed a POD incidence of 19.6% (95% CI: 16.9-22.3%) in males and 18.3% (95% CI: 15.7-20.9%) in females. The year of publication subgroup analysis revealed a POD incidence of 20.3% (95% CI: 17.4-23.3%) after 2018 and 14.6 (95% CI: 11.6-17.6%) in 2018 and before. In the subgroup of surgical types, the incidence of hip fracture surgery POD was 20.7% (95% CI: 17.6-24.3%), the incidence of non-cardiac surgery POD was 18.4% (95% CI: 11.8-25.1%), the incidence of orthopedic surgery POD was 16.6% (95% CI: 11.8-21.5%), the incidence of abdominal neoplasms surgery POD was 14.3% (95% CI: 7.6-21.1%); the incidence of abdominal surgery POD was 13.9% (95% CI: 6.4-21.4%). The anesthesia methods subgroup revealed a POD incidence of 21.5% (95% CI: 17.9-25.1%) for general anesthesia, 15.0% (95% CI: 10.6-19.3%) for intraspinal anesthesia, and 8.3% (95% CI: 10.6-19.3%) for regional anesthesia. The measurement tool subgroup revealed a POD incidence of 19.3% (95% CI: 16.7-21.9%) with CAM and 16.8% (95% CI: 12.6-21.0%) with DSM. The sample size subgroup revealed a POD incidence of 19.4% (95% CI: 16.8-22.1%) for patients ≤ 500 and 15.3% (95% CI: 11.0-19.7%) for patients > 500. The sensitivity analysis suggested that the pooled incidence of postoperative delirium in this study was stable. Conclusion Our systematic review of the incidence of delirium after non-cardiac surgery in elderly Chinese patients revealed a high incidence of postoperative delirium. Except for cardiac surgery, the incidence of postoperative delirium was higher for hip fracture surgery than for other types of surgery. However, this finding must be further explored in future large-sample studies. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: PROSPERO CRD42023397883.
Collapse
Affiliation(s)
- Xiao-Yan Gong
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Dong-Jiang Hou
- School of Medicine and Life Sciences, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Yang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jia-li He
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Ming-Jin Cai
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Wei Wang
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Xian-Ying Lu
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| | - Jing Gao
- School of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan, China
| |
Collapse
|
32
|
Nakamura R, Miyamoto K, Tsuji K, Ozaki K, Kunimoto H, Honda K, Nishimura Y, Kato S. The impact of a preoperative nurse-led orientation program on postoperative delirium after cardiovascular surgery: a retrospective single-center observational study. J Intensive Care 2023; 11:20. [PMID: 37198714 PMCID: PMC10191397 DOI: 10.1186/s40560-023-00666-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 04/28/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND Postoperative delirium in intensive care is common and associated with mortality, cognitive impairment, prolonged hospital stays and high costs. We evaluate whether a nurse-led orientation program could reduce the incidence of delirium in the intensive care unit after cardiovascular surgery. METHODS In this retrospective cohort study, we enrolled patients admitted to the intensive care unit for planned cardiovascular surgery between January 2020 and December 2021. A nurse-led orientation program based on a preoperative visit was routinely introduced from January 2021. We assessed the association between these visits and postoperative delirium in the intensive care unit. We also assessed predictors of postoperative delirium with baseline and intraoperative characteristics. RESULTS Among 253 patients with planned cardiovascular surgery, 128 (50.6%) received preoperative visits. Valve surgery comprised 44.7%, coronary surgery 31.6%, and aortic surgery 20.9%. Cardiopulmonary bypass use and transcatheter surgery were 60.5% and 12.3%, respectively. Incidence of delirium was lower in patients that received preoperative visits, and median hospital stay was shorter than in those without visits (18 patients [14.1%] vs 34 patients [27.2%], P < 0.01; 14 days vs 17 days, P < 0.01). After adjusting predefined confounders, preoperative visits were independently associated with decreased incidence of delirium (adjusted odds ratio [aOR] 0.45; 95% confidence interval [95% CI] 0.22-0.84). Other predictors of delirium were higher European System for Cardiac Operative Risk Evaluation II score and lower minimum intraoperative cerebral oxygen saturation. CONCLUSIONS A preoperative nurse-led orientation program was associated with reduction of postoperative delirium and could be effective against postoperative delirium after cardiovascular surgery. Trial registration UMIN Clinical Trial Registry no. UMIN000048142. Registered 22, July, 2022, retrospectively registered, https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000054862 .
Collapse
Affiliation(s)
- Ryo Nakamura
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan.
| | - Kyohei Miyamoto
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kaori Tsuji
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Kana Ozaki
- Department of Nursing, Wakayama Medical University Hospital, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8510, Japan
| | - Hideki Kunimoto
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Kentaro Honda
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Yoshiharu Nishimura
- Department of Thoracic and Cardiovascular Surgery, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| | - Seiya Kato
- Department of Emergency and Critical Care Medicine, Wakayama Medical University, 811-1 Kimiidera, Wakayama City, Wakayama, 641-8509, Japan
| |
Collapse
|
33
|
Byrnes T, Woodward J. Implementing a Delirium Risk Stratification Tool and Rounds to Identify and Prevent Delirium in Hospitalized Older Adults. J Nurs Care Qual 2023; 38:158-163. [PMID: 36322042 DOI: 10.1097/ncq.0000000000000676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Up to 40% of delirium cases are preventable, and early identification is key to improve patient outcomes. PURPOSE To implement and evaluate a multidisciplinary delirium intervention program. INTERVENTION The delirium intervention program targeted patients at high risk for delirium and included patient and nurse education, risk stratification, multidisciplinary rounds, a nonpharmacological intervention bundle, and a treatment order set. RESULTS After implementation, there was a reduction in length of stay of 6.3 days ( P = .01), a 24% decrease in disposition to a skilled nursing facility ( P = .05), and increased detection of delirium by nurses. CONCLUSION Positive patient outcomes were achieved by employing a multifactorial approach for delirium identification, prevention, and management. The components of this quality improvement project provide guidance to hospitals seeking to develop a delirium intervention program.
Collapse
Affiliation(s)
- Tru Byrnes
- Carolinas Medical Center, Charlotte, North Carolina (Dr Byrnes); and Geriatric Medicine CHS Senior Care, Charlotte, North Carolina (Dr Woodward)
| | | |
Collapse
|
34
|
Mennig EF, Schäfer SK, Eschweiler GW, Rapp MA, Thomas C, Wurm S. The relationship between pre-surgery self-rated health and changes in functional and mental health in older adults: insights from a prospective observational study. BMC Geriatr 2023; 23:203. [PMID: 37003994 PMCID: PMC10064967 DOI: 10.1186/s12877-023-03861-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 02/27/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Elective surgeries are among the most common health stressors in later life and put a significant risk at functional and mental health, making them an important target of research into healthy aging and physical resilience. Large-scale longitudinal research mostly conducted in non-clinical samples provided support of the predictive value of self-rated health (SRH) for both functional and mental health. Thus, SRH may have the potential to predict favorable adaptation processes after significant health stressors, that is, physical resilience. So far, a study examining the interplay between SRH, functional and mental health and their relative importance for health changes in the context of health stressors was missing. The present study aimed at addressing this gap. METHODS We used prospective data of 1,580 inpatients (794 complete cases) aged 70 years or older of the PAWEL study, collected between October 2017 and May 2019 in Germany. Our analyses were based on SRH, functional health (Barthel Index) and self-reported mental health problems (PHQ-4) before and 12 months after major elective surgery. To examine changes and interrelationships in these health indicators, bivariate latent change score (BLCS) models were applied. RESULTS Our analyses provided evidence for improvements of SRH, functional and mental health from pre-to-post surgery. BLCS models based on complete cases and the total sample pointed to a complex interplay of SRH, functional health and mental health with bidirectional coupling effects. Better pre-surgery SRH was associated with improvements in functional and mental health, and better pre-surgery functional health and mental health were associated with improvements in SRH from pre-to-post surgery. Effects of pre-surgery SRH on changes in functional health were smaller than those of functional health on changes in SRH. CONCLUSIONS Meaningful changes of SRH, functional and mental health and their interplay could be depicted for the first time in a clinical setting. Our findings provide preliminary support for SRH as a physical resilience factor being associated with improvements in other health indicators after health stressors. Longitudinal studies with more timepoints are needed to fully understand the predictive value of SRH for multidimensional health. TRIAL REGISTRATION PAWEL study, German Clinical Trials Register, number DRKS00013311. Registered 10 November 2017 - Retrospectively registered, https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013311 .
Collapse
Affiliation(s)
- Eva F Mennig
- Department of Prevention Research and Social Medicine, Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475, Greifswald, Germany
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Priessnitzweg 24, 70374, Stuttgart, Germany
| | - Sarah K Schäfer
- Department of Prevention Research and Social Medicine, Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475, Greifswald, Germany
- Leibniz Institute for Resilience Research, Wallstrasse 7, 55122, Mainz, Germany
| | - Gerhard W Eschweiler
- Geriatric Center at the University Hospital Tübingen, University Hospital of Psychiatry and Psychotherapy Tübingen, Calwerstrasse 14, 72076, Tübingen, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Calwerstrasse 14, 72076, Tübingen, Germany
| | - Michael A Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469, Potsdam, Germany
| | - Christine Thomas
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Priessnitzweg 24, 70374, Stuttgart, Germany
- Department of Psychiatry and Psychotherapy, University Hospital of Tübingen, Calwerstrasse 14, 72076, Tübingen, Germany
| | - Susanne Wurm
- Department of Prevention Research and Social Medicine, Institute for Community Medicine, University Medicine Greifswald, Walther-Rathenau-Strasse 48, 17475, Greifswald, Germany.
| |
Collapse
|
35
|
Ní Chróinín D, Alexandrou E, Frost SA. Delirium in the intensive care unit and its importance in the post-operative context: A review. Front Med (Lausanne) 2023; 10:1071854. [PMID: 37064025 PMCID: PMC10098316 DOI: 10.3389/fmed.2023.1071854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 02/10/2023] [Indexed: 04/18/2023] Open
Abstract
The burden of delirium in the intensive care setting is a global priority. Delirium affects up to 80% of patients in intensive care units; an episode of delirium is often distressing to patients and their families, and delirium in patients within, or outside of, the intensive care unit (ICU) setting is associated with poor outcomes. In the short term, such poor outcomes include longer stay in intensive care, longer hospital stay, increased risk of other hospital-acquired complications, and increased risk of hospital mortality. Longer term sequelae include cognitive impairment and functional dependency. While medical category of admission may be a risk factor for poor outcomes in critical care populations, outcomes for surgical ICU admissions are also poor, with dependency at hospital discharge exceeding 30% and increased risk of in-hospital mortality, particularly in vulnerable groups, with high-risk procedures, and resource-scarce settings. A practical approach to delirium prevention and management in the ICU setting is likely to require a multi-faceted approach. Given the good evidence for the prevention of delirium among older post-operative outside of the intensive care setting, simple non-pharmacological interventions should be effective among older adults post-operatively who are cared for in the intensive care setting. In response to this, the future ICU environment will have a range of organizational and distinct environmental characteristics that are directly targeted at preventing delirium.
Collapse
Affiliation(s)
- Danielle Ní Chróinín
- Liverpool Hospital, Liverpool, NSW, Australia
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia
| | - Evan Alexandrou
- Liverpool Hospital, Liverpool, NSW, Australia
- South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia
- Centre for Applied Nursing Research, School of Nursing and Midwifery, Western Sydney University and Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| | - Steven A. Frost
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
- SWS Nursing and Midwifery Research Alliance, Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| |
Collapse
|
36
|
Austin CA, Palanca BJA, Smith K, Chapin B, Lin SY, Khan S, Lindroth H, Maya K, Oldham M. American Delirium Society 2022 Year in Review: Highlighting the Year's Most Impactful Delirium Research. DELIRIUM COMMUNICATIONS 2023; 2023:10.56392/001c.73356. [PMID: 38361911 PMCID: PMC10869120 DOI: 10.56392/001c.73356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background Since 2015, the American Delirium Society (ADS) Research Committee has conducted an annual survey of the delirium literature for presentation in its year-in-review session. Our objectives were to describe the review process used for the 2021-2022 and to summarise the selected publications. Methods Each member of the ADS Research Committee nominated up to 6 publications considered to be the most impactful primary delirium research published from September 1, 2021, to July 31, 2022. The 24 nominated studies were divided into three categories balanced by number of articles: medical intervention trials, non-medical intervention trials, and delirium detection/basic science studies. Each ADS Research Committee member ranked all studies in their assigned category for methodological rigor and for impact, each being scored as 0-10, for a total score of 0-20. It was decided a priori to select the top three highest-scoring articles in each category for presentation, with ties adjudicated by Committee consensus. Results Nineteen Research Committee members served as reviewers. Scores for each category were similar: medical interventions mean (standard deviation) 12.8 (1.1), non-medical interventions 13.1 (1.1), and detection/basic science 12.6 (1.0). We summarise the results of the papers presented in the 2022 ADS year-in-review session. Conclusion The diversity of studies presented for the 2022 ADS year-in-review session illustrates the breadth of the delirium field and the growing number of clinical trials. The dissemination of publications across a broad, diverse array of journals provides further justification of the need for delirium-specific journals.
Collapse
Affiliation(s)
- C. Adrian Austin
- Corresponding Author: C. Adrian Austin, MD, MSCR, Clinical Instructor, Division of Pulmonary and Critical Care Medicine Division of Geriatric Medicine, University of North Carolina at Chapel Hill, 130 Mason Farm Rd, CB 7020, Chapel Hill, NC 27514 919-966-2531,
| | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Steenblock J, Braisch U, Brefka S, Thomas C, Eschweiler GW, Rapp M, Metz B, Maurer C, von Arnim CAF, Herrmann ML, Wagner S, Denkinger M, Dallmeier D. Frailty index and its association with the onset of postoperative delirium in older adults undergoing elective surgery. BMC Geriatr 2023; 23:90. [PMID: 36774453 PMCID: PMC9921654 DOI: 10.1186/s12877-022-03663-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/30/2022] [Indexed: 02/13/2023] Open
Abstract
BACKGROUND The association of frailty based on the accumulation of deficits with postoperative delirium (POD) has been poorly examined. We aimed to analyze this association in older patients undergoing elective surgery. METHODS Preoperative data was used to build a 30-item frailty index (FI) for participants of the PAWEL-study. Delirium was defined by a combination of I-CAM and chart review. Using logistic regressions models we analysed the association between frailty and POD adjusting for age, sex, smoking, alcohol consumption, education and type of surgery. RESULTS Among 701 participants (mean age 77.1, 52.4% male) median FI was 0.27 (Q1 0.20| Q3 0.34), with 528 (75.3%) frail participants (FI ≥ 0.2). Higher median FI were seen in orthopedic than cardiac surgery patients (0.28 versus 0.23), and in women (0.28 versus 0.25 in men). Frail participants showed a higher POD incidence proportion (25.4% versus 17.9% in non-frail). An increased odds for POD was observed in frail versus non-frail participants (OR 2.14 [95% CI 1.33, 3.44], c-statistic 0.71). A 0.1 increment of FI was associated with OR 1.57 [95% CI 1.30, 1.90] (c-statistic 0.72) for POD. No interaction with sex or type of surgery was detected. Adding timed-up-and-go-test and handgrip strength to the FI did not improve discrimination. CONCLUSION Our data showed a significant association between frailty defined through a 30-item FI and POD among older adults undergoing elective surgery. Adding functional measures to the FI did not improve discrimination. Hence, our preoperative 30-item FI can help to identify patients with increased odds for POD. TRIAL REGISTRATION PAWEL and PAWEL-R (sub-) study were registered on the German Clinical Trials Register (number DRKS00013311 and DRKS00012797).
Collapse
Affiliation(s)
- Janina Steenblock
- Agaplesion Bethesda Clinic, Ulm, Germany ,Geriatric Center Ulm/Alb-Donau, Ulm, Germany ,grid.410712.10000 0004 0473 882XInstitute for Geriatric Research, University Clinic Ulm, Ulm, Germany ,grid.6582.90000 0004 1936 9748Medical Faculty, Ulm University, Ulm, Germany
| | - Ulrike Braisch
- Agaplesion Bethesda Clinic, Ulm, Germany ,Geriatric Center Ulm/Alb-Donau, Ulm, Germany ,grid.6582.90000 0004 1936 9748Institute of Epidemiology and Medical Biometry, Ulm University, Ulm, Germany
| | - Simone Brefka
- Agaplesion Bethesda Clinic, Ulm, Germany ,Geriatric Center Ulm/Alb-Donau, Ulm, Germany ,grid.410712.10000 0004 0473 882XInstitute for Geriatric Research, University Clinic Ulm, Ulm, Germany
| | - Christine Thomas
- Department of Old Age Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany ,grid.7708.80000 0000 9428 7911Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany ,grid.239395.70000 0000 9011 8547Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215 USA
| | - Gerhard W. Eschweiler
- grid.411544.10000 0001 0196 8249Geriatric Center at the University Hospital Tuebingen, Tuebingen, Germany
| | - Michael Rapp
- grid.11348.3f0000 0001 0942 1117Department of Social and Preventive Medicine, University of Potsdam, Am Neuen Palais 10, 14469 Potsdam, Germany
| | - Brigitte Metz
- Geriatric Center Karlsruhe, ViDia Christian Clinics Karlsruhe, Karlsruhe, Germany
| | - Christoph Maurer
- grid.5963.9Center for Geriatric Medicine and Gerontology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christine A. F. von Arnim
- grid.411984.10000 0001 0482 5331Department of Geriatrics, University Medical Center Göttingen, Göttingen, Germany
| | - Matthias. L. Herrmann
- grid.7708.80000 0000 9428 7911Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany ,grid.411544.10000 0001 0196 8249Geriatric Center at the University Hospital Tuebingen, Tuebingen, Germany
| | - Sören Wagner
- grid.239395.70000 0000 9011 8547Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215 USA ,grid.419842.20000 0001 0341 9964Department of Anaesthesiology, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174 Stuttgart, Germany
| | - Michael Denkinger
- Agaplesion Bethesda Clinic, Ulm, Germany ,Geriatric Center Ulm/Alb-Donau, Ulm, Germany ,grid.410712.10000 0004 0473 882XInstitute for Geriatric Research, University Clinic Ulm, Ulm, Germany ,grid.6582.90000 0004 1936 9748Medical Faculty, Ulm University, Ulm, Germany
| | - Dhayana Dallmeier
- Agaplesion Bethesda Clinic, Ulm, Germany. .,Geriatric Center Ulm/Alb-Donau, Ulm, Germany. .,Medical Faculty, Ulm University, Ulm, Germany. .,Department of Epidemiology, Boston University School of Public Health, Boston, USA.
| |
Collapse
|
38
|
Alvarez EA, Rojas VA, Caipo LI, Galaz MM, Ponce DP, Gutierrez RG, Salech F, Tobar E, Reyes FI, Vergara RC, Egaña JI, Briceño CA, Penna A. Non-pharmacological prevention of postoperative delirium by occupational therapy teams: A randomized clinical trial. Front Med (Lausanne) 2023; 10:1099594. [PMID: 36817762 PMCID: PMC9931896 DOI: 10.3389/fmed.2023.1099594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/16/2023] [Indexed: 02/05/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Evelyn A. Alvarez
- Terapia Ocupacional, Universidad Central de Chile, Santiago, Chile,Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Universidad de Chile, Santiago, Chile
| | - Veronica A. Rojas
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Lorena I. Caipo
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Melany M. Galaz
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Daniela P. Ponce
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile
| | - Rodrigo G. Gutierrez
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Felipe Salech
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Sección de Geriatría, Departamento de Medicina, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Eduardo Tobar
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Fernando I. Reyes
- Servicio de Anestesiología, Hospital Santiago Oriente Doctor Luis Tisné Brousse, Santiago, Chile
| | - Rodrigo C. Vergara
- Núcleo de Bienestar y Desarrollo Humano (NUBIDEH), Centro de Investigación en Educación (CIE-UMCE), Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile,Facultad de Artes y Educación Física, Departamento de Kinesiología, Universidad Metropolitana de Ciencias de la Educación, Santiago, Chile,Centro Nacional de Inteligencia Artificial (CENIA), Santiago, Chile
| | - Jose I. Egaña
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Constanza A. Briceño
- Departamento de Terapia Ocupacional y Ciencia de la Ocupación, Universidad de Chile, Santiago, Chile
| | - Antonello Penna
- Centro de Investigación Clínica Avanzada (CICA), Hospital Clínico y Facultad de Medicina de la Universidad de Chile, Santiago, Chile,Departamento de Anestesiología y Medicina Perioperatoria, Hospital Clínico de la Universidad de Chile, Santiago, Chile,*Correspondence: Antonello Penna,
| |
Collapse
|
39
|
Azhar G, Sharma S, Lau O, Alkharisi B, Anandam A, Isa S, Mendiratta P, Pangle AK, Coker K, Wei J. Quality Improvement in Delirium Health Literacy in Older Adult Patients and Their Caregivers Attending a Geriatric Clinic. Clin Interv Aging 2022; 17:1901-1906. [PMID: 36597428 PMCID: PMC9805724 DOI: 10.2147/cia.s388325] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 12/06/2022] [Indexed: 12/29/2022] Open
Abstract
Background Delirium is a common medical condition that is highly prevalent in older adults who are at increased risk for its development with any illness, post-surgery or during hospitalization. The purpose of our study was to evaluate the health literacy of older adult patients and their caregivers about delirium, offer a brief educational intervention, and reevaluate their knowledge post intervention. Materials and Methods We conducted a quality improvement project, focused on delirium health literacy in older adult patients ≥60 years and their caregivers. Delirium knowledge of participants was evaluated in a pre-education survey after which they were given a delirium education booklet to read. A post-education delirium survey was conducted within 2-3 weeks of the educational intervention. Chi-square test was used to analyze the knowledge base of older adults. Results The study population consisted of a total of 70 older adults who participated in pre-education (n=35) and post-education (n=35) surveys. Older adult patients and their caregivers had significant knowledge gaps about the potential causes or etiologies, risk factors, symptomatology, and prevention of delirium in the pre-education survey. After the educational intervention, in the post-education survey, there were overall improvements in knowledge base of older adults in differentiating delirium with dementia (43% vs 94%, p<0.01) recognizing signs and symptoms (77% vs 94%, p<0.05), complications (76% vs 100%, p<0.01) and identifying the etiological factors associated with delirium. Conclusion The quality improvement project demonstrated that older adults and caregivers have significant knowledge deficits about the common condition of delirium. This study also demonstrated that older adults were able to improve their health literacy regarding delirium after the intervention. Appropriate education on delirium for patients and caregivers might help in earlier identification, prevention, and better overall management of delirium.
Collapse
Affiliation(s)
- Gohar Azhar
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA,Correspondence: Gohar Azhar, Email
| | - Shakshi Sharma
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Onna Lau
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Bader Alkharisi
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Anil Anandam
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Sakiru Isa
- Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Priya Mendiratta
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Amanda K Pangle
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Karen Coker
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Jeanne Wei
- Department of Geriatrics, Donald W. Reynolds Institute of Aging, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| |
Collapse
|
40
|
Ní Chróinín D, Chuan A. Post-operative delirium in the patient with hip fracture: The journey from hospital arrival to discharge. Front Med (Lausanne) 2022; 9:1080253. [PMID: 36507517 PMCID: PMC9728584 DOI: 10.3389/fmed.2022.1080253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
Delirium- an acute disorder of attention and cognition- is the commonest complication following hip fracture. Patients with hip fracture are particularly vulnerable to delirium, and many of the lessons from the care of the patient with hip fracture will extend to other surgical cohorts. Prevention and management of delirium for patients presenting with hip fracture, extending along a continuum from arrival through to the post-operative setting. Best practice guidelines emphasize multidisciplinary care including management by an orthogeriatric service, regular delirium screening, and multimodal interventions. The evidence base for prevention is strongest in terms of multifaceted interventions, while once delirium has set in, early recognition and identification of the cause are key. Integration of effective strategies is often suboptimal, and may be supported by approaches such as interactive teaching methodologies, routine feedback, and clear protocol dissemination. Partnering with patients and carers will support person centered care, improve patient experiences, and may improve outcomes. Ongoing work needs to focus on implementing recognized best practice, in order to minimize the health, social and economic costs of delirium.
Collapse
Affiliation(s)
- Danielle Ní Chróinín
- Liverpool Hospital, Liverpool, NSW, Australia,South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia,*Correspondence: Danielle Ní Chróinín,
| | - Alwin Chuan
- Liverpool Hospital, Liverpool, NSW, Australia,South Western Sydney Clinical School, UNSW Sydney, Liverpool, NSW, Australia,Ingham Institute of Applied Medical Research, Liverpool, NSW, Australia
| |
Collapse
|
41
|
MacLullich AMJ, Hosie A, Tieges Z, Davis DHJ. Three key areas in progressing delirium practice and knowledge: recognition and relief of distress, new directions in delirium epidemiology and developing better research assessments. Age Ageing 2022; 51:afac271. [PMID: 36441120 PMCID: PMC9704028 DOI: 10.1093/ageing/afac271] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Indexed: 11/29/2022] Open
Abstract
Delirium presents formidable challenges: it affects one in four of older hospitalised adults, greatly elevates the risk of multiple short- and long-term complications including dementia and causes significant distress. Delirium care remains generally poor. Yet, there are clear grounds for optimism; the last decade has seen impactful policy advances and a tripling of research output. Here, we highlight three linked areas which have strong potential to transform delirium practice and knowledge in the near term. Delirium-related distress is strikingly underrepresented in practice guidance and research. Proactive recognition combined with effective clinical responses based on good communication provides a critical and largely untapped opportunity to improve care. Delirium epidemiology research is well positioned to produce novel insights through advanced prospective designs in populations such as emergency medical patients with detailed pre-, intra- and post-delirium assessments allied with fluid, imaging and other biomarkers. Research-grade assessment of delirium currently involves a chaotic array of tools, methods and diagnostic algorithms. Areas for development: expand and analytically distinguish the range of features assessed (including distress), optimise feature assessment including use of validated neuropsychological tests where possible, produce standardised algorithms which articulate explicit pathways from features to diagnosis, and create new fine-grained approaches to the measurement of severity. Delirium practice and knowledge show accelerating growth. This is encouraging but much of the necessary progress is still to come. Innovation in these three highlighted areas, as well as many others, will open up exciting possibilities in enhancing the care of patients with this common and often devastating condition.
Collapse
Affiliation(s)
- Alasdair M J MacLullich
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Annmarie Hosie
- School of Nursing and Midwifery, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
- The Cunningham Centre for Palliative Care, St Vincent’s Health Network Sydney, Darlinghurst, NSW, Australia
- IMPACCT – Improving Palliative, Aged and Chronic Care through Research and Translation, University of Technology Sydney, Ultimo, NSW, Australia
| | - Zoë Tieges
- Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, UK
- SMART Technology Centre, School of Computing, Engineering and Built Environment, Glasgow Caledonian University, Glasgow, UK
| | - Daniel H J Davis
- MRC Unit for Lifelong Health and Ageing, University College London, London, UK
| |
Collapse
|
42
|
Oosterhoff JHF, Oberai T, Karhade AV, Doornberg JN, Kerkhoffs GM, Jaarsma RL, Schwab JH, Heng M. Does the SORG Orthopaedic Research Group Hip Fracture Delirium Algorithm Perform Well on an Independent Intercontinental Cohort of Patients With Hip Fractures Who Are 60 Years or Older? Clin Orthop Relat Res 2022; 480:2205-2213. [PMID: 35561268 PMCID: PMC10476833 DOI: 10.1097/corr.0000000000002246] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/22/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Postoperative delirium in patients aged 60 years or older with hip fractures adversely affects clinical and functional outcomes. The economic cost of delirium is estimated to be as high as USD 25,000 per patient, with a total budgetary impact between USD 6.6 to USD 82.4 billion annually in the United States alone. Forty percent of delirium episodes are preventable, and accurate risk stratification can decrease the incidence and improve clinical outcomes in patients. A previously developed clinical prediction model (the SORG Orthopaedic Research Group hip fracture delirium machine-learning algorithm) is highly accurate on internal validation (in 28,207 patients with hip fractures aged 60 years or older in a US cohort) in identifying at-risk patients, and it can facilitate the best use of preventive interventions; however, it has not been tested in an independent population. For an algorithm to be useful in real life, it must be valid externally, meaning that it must perform well in a patient cohort different from the cohort used to "train" it. With many promising machine-learning prediction models and many promising delirium models, only few have also been externally validated, and even fewer are international validation studies. QUESTION/PURPOSE Does the SORG hip fracture delirium algorithm, initially trained on a database from the United States, perform well on external validation in patients aged 60 years or older in Australia and New Zealand? METHODS We previously developed a model in 2021 for assessing risk of delirium in hip fracture patients using records of 28,207 patients obtained from the American College of Surgeons National Surgical Quality Improvement Program. Variables included in the original model included age, American Society of Anesthesiologists (ASA) class, functional status (independent or partially or totally dependent for any activities of daily living), preoperative dementia, preoperative delirium, and preoperative need for a mobility aid. To assess whether this model could be applied elsewhere, we used records from an international hip fracture registry. Between June 2017 and December 2018, 6672 patients older than 60 years of age in Australia and New Zealand were treated surgically for a femoral neck, intertrochanteric hip, or subtrochanteric hip fracture and entered into the Australian & New Zealand Hip Fracture Registry. Patients were excluded if they had a pathological hip fracture or septic shock. Of all patients, 6% (402 of 6672) did not meet the inclusion criteria, leaving 94% (6270 of 6672) of patients available for inclusion in this retrospective analysis. Seventy-one percent (4249 of 5986) of patients were aged 80 years or older, after accounting for 5% (284 of 6270) of missing values; 68% (4292 of 6266) were female, after accounting for 0.06% (4 of 6270) of missing values, and 83% (4690 of 5661) of patients were classified as ASA III/IV, after accounting for 10% (609 of 6270) of missing values. Missing data were imputed using the missForest methodology. In total, 39% (2467 of 6270) of patients developed postoperative delirium. The performance of the SORG hip fracture delirium algorithm on the validation cohort was assessed by discrimination, calibration, Brier score, and a decision curve analysis. Discrimination, known as the area under the receiver operating characteristic curves (c-statistic), measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities, a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. RESULTS The SORG hip fracture algorithm, when applied to an external patient cohort, distinguished between patients at low risk and patients at moderate to high risk of developing postoperative delirium. The SORG hip fracture algorithm performed with a c-statistic of 0.74 (95% confidence interval 0.73 to 0.76). The calibration plot showed high accuracy in the lower predicted probabilities (intercept -0.28, slope 0.52) and a Brier score of 0.22 (the null model Brier score was 0.24). The decision curve analysis showed that the model can be beneficial compared with no model or compared with characterizing all patients as at risk for developing delirium. CONCLUSION Algorithms developed with machine learning are a potential tool for refining treatment of at-risk patients. If high-risk patients can be reliably identified, resources can be appropriately directed toward their care. Although the current iteration of SORG should not be relied on for patient care, it suggests potential utility in assessing risk. Further assessment in different populations, made easier by international collaborations and standardization of registries, would be useful in the development of universally valid prediction models. The model can be freely accessed at: https://sorg-apps.shinyapps.io/hipfxdelirium/ . LEVEL OF EVIDENCE Level III, therapeutic study.
Collapse
Affiliation(s)
- Jacobien H. F. Oosterhoff
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Amsterdam University Medical Centers, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, the Netherlands
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Tarandeep Oberai
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Aditya V. Karhade
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Job N. Doornberg
- Department of Orthopaedic Surgery, University Medical Centre Groningen, University of Groningen, the Netherlands
| | - Gino M.M.J. Kerkhoffs
- Amsterdam University Medical Centers, University of Amsterdam, Department of Orthopaedic Surgery, Amsterdam Movement Sciences, the Netherlands
| | - Ruurd L. Jaarsma
- Department of Orthopaedic and Trauma Surgery, Flinders Medical Centre, Flinders University, Adelaide, SA, Australia
| | - Joseph H. Schwab
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Marilyn Heng
- Harvard Medical School Orthopedic Trauma Initiative, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
43
|
Myles PS, Yeung J, Beattie WS, Ryan EG, Heritier S, McArthur CJ. Platform trials for anaesthesia and perioperative medicine: a narrative review. Br J Anaesth 2022; 130:677-686. [PMID: 36456249 DOI: 10.1016/j.bja.2022.10.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/27/2022] [Accepted: 10/28/2022] [Indexed: 11/29/2022] Open
Abstract
Large randomised trials provide the most reliable evidence of effectiveness of new treatments in clinical practice. However, the time and resources required to complete such trials can be daunting. An overarching clinical trial platform focused on a single condition or type of surgery, aiming to compare several treatments, with an option to stop any or add in new treatment options, can provide greater efficiency. This has the potential to accelerate knowledge acquisition and identify effective, ineffective, or harmful treatments faster. The master protocol of the platform defines the study population(s) and standardised procedures. Ineffective or harmful treatments can be discarded or study drug dose modified during the life cycle of the trial. Other adaptive elements that can be modified include eligibility criteria, required sample size for any comparison(s), randomisation assignment ratio, and the addition of other promising treatment options. There are excellent opportunities for anaesthetists to establish platform trials in perioperative medicine. Platform trials are highly efficient, with the potential to provide quicker answers to important clinical questions that lead to improved patient care.
Collapse
|
44
|
Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design. BMC Geriatr 2022; 22:754. [PMID: 36109707 PMCID: PMC9479259 DOI: 10.1186/s12877-022-03442-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/07/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment. METHODS Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3). DISCUSSION Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients. TRIAL REGISTRATION German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.
Collapse
|
45
|
Burke A, Gupta A, Houchens N. Quality and Safety in the Literature: September 2022. BMJ Qual Saf 2022; 31:689-694. [PMID: 35981736 DOI: 10.1136/bmjqs-2022-015160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 05/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Anna Burke
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Ashwin Gupta
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Nathan Houchens
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA.,Medicine Service, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| |
Collapse
|
46
|
Vacas S, Canales C, Deiner SG, Cole DJ. Perioperative Brain Health in the Older Adult: A Patient Safety Imperative. Anesth Analg 2022; 135:316-328. [PMID: 35584550 PMCID: PMC9288500 DOI: 10.1213/ane.0000000000006090] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While people 65 years of age and older represent 16% of the population in the United States, they account for >40% of surgical procedures performed each year. Maintaining brain health after anesthesia and surgery is not only important to our patients, but it is also an increasingly important patient safety imperative for the specialty of anesthesiology. Aging is a complex process that diminishes the reserve of every organ system and often results in a patient who is vulnerable to the stress of surgery. The brain is no exception, and many older patients present with preoperative cognitive impairment that is undiagnosed. As we age, a number of changes occur in the human brain, resulting in a patient who is less resilient to perioperative stress, making older adults more susceptible to the phenotypic expression of perioperative neurocognitive disorders. This review summarizes the current scientific and clinical understanding of perioperative neurocognitive disorders and recommends patient-centered, age-focused interventions that can better mitigate risk, prevent harm, and improve outcomes for our patients. Finally, it discusses the emerging topic of sleep and cognitive health and other future frontiers of scientific inquiry that might inform clinical best practices.
Collapse
Affiliation(s)
- Susana Vacas
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Cecilia Canales
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| | - Stacie G Deiner
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - Daniel J Cole
- From the Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
| |
Collapse
|
47
|
Preoperative and Postoperative Cognitive Assessment in Geriatric Patients Following Acute Traumatic Injuries: Towards Improving Geriatric Trauma Outcomes. J Surg Res 2022; 277:352-364. [PMID: 35567991 DOI: 10.1016/j.jss.2022.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 03/09/2022] [Accepted: 04/08/2022] [Indexed: 11/22/2022]
Abstract
INTRODUCTION A growing percentage of the US population is over the age of 65, and geriatrics account for a large portion of trauma admissions, expected to reach nearly 40% by 2050. Cognitive status is important for operative management, especially in elderly populations. This study aims to investigate preoperative and postoperative cognitive function assessment tools in geriatric patients following acute trauma and associated outcomes, including functional status, postdischarge disposition, mortality, and hospital length of stay (H-LOS). METHODS A literature search was conducted using Medline/PubMed, Google Scholar, Embase, JAMA Networks, and Cochrane databases for studies investigating the use of cognitive assessment tools for geriatric patients with acute trauma. The last literature search was conducted on November 13, 2021. RESULTS Ten studies were included in this review, of which five focused on preoperative cognitive assessment and five focused on postoperative. The evidence suggests patients with preoperative cognitive impairment had worse functional status, mortality, and postdischarge disposition along with increased LOS. Acute trauma patients with postoperative cognitive impairment also had worse functional status, mortality, and adverse postdischarge disposition. CONCLUSIONS Preoperative and postoperative cognitive impairment is common in geriatric patients with acute trauma and is associated with worse outcomes, including decreased functional status, increased LOS, and adverse discharge disposition. Cognitive assessment tools such as MMSE, MoCA, and CAM are fast and effective at detecting cognitive impairment in the acute trauma setting and allow clinicians to address preoperative or postoperative cognitive impairments to improve patient outcomes.
Collapse
|
48
|
Herrmann ML, Boden C, Maurer C, Kentischer F, Mennig E, Wagner S, Conzelmann LO, Förstner BR, Rapp MA, von Arnim CAF, Denkinger M, Eschweiler GW, Thomas C. Anticholinergic Drug Exposure Increases the Risk of Delirium in Older Patients Undergoing Elective Surgery. Front Med (Lausanne) 2022; 9:871229. [PMID: 35602472 PMCID: PMC9121116 DOI: 10.3389/fmed.2022.871229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/29/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a common and serious adverse event of surgery in older people. Because of its great impact on patients' safety and quality of life, identification of modifiable risk factors could be useful. Although preoperative medication intake is assumed to be an important modifiable risk factor, the impact of anticholinergic drugs on the occurrence of POD seems underestimated in elective surgery. The aim of this study was to investigate the association between preoperative anticholinergic burden and POD. We hypothesized that a high preoperative anticholinergic burden is an independent, potentially modifiable predisposing and precipitating factor of POD in older people. Methods Between November 2017 and April 2019, 1,470 patients of 70 years and older undergoing elective orthopedic, general, cardiac, or vascular surgery were recruited in the randomized, prospective, multicenter PAWEL trial. Anticholinergic burden of a sub-cohort of 899 patients, who did not receive a multimodal intervention for preventing POD, was assessed by two different tools at hospital admission: The established Anticholinergic Risk Scale (ARS) and the recently developed Anticholinergic Burden Score (ABS). POD was detected by confusion assessment method (CAM) and a validated post discharge medical record review. Logistic regression analyses were performed to evaluate the association between anticholinergic burden and POD. Results POD was observed in 210 of 899 patients (23.4%). Both ARS and ABS were independently associated with POD. The association persisted after adjustment for relevant confounding factors such as age, sex, comorbidities, preoperative cognitive and physical status, number of prescribed drugs, surgery time, type of surgery and anesthesia, usage of heart-lung-machine, and treatment in intensive care unit. If a patient was taking one of the 56 drugs listed in the ABS, risk for POD was 2.7-fold higher (OR = 2.74, 95% CI = 1.55–4.94) and 1.5-fold higher per additional point on the ARS (OR = 1.54, 95% CI = 1.15–2.02). Conclusion Preoperative anticholinergic drug exposure measured by ARS or ABS was independently associated with POD in older patients undergoing elective surgery. Therefore, identification, discontinuation or substitution of anticholinergic medication prior to surgery may be a promising approach to reduce the risk of POD in older patients.
Collapse
Affiliation(s)
- Matthias L. Herrmann
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- *Correspondence: Matthias L. Herrmann
| | - Cindy Boden
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christoph Maurer
- Department of Neurology and Neurophysiology, Medical Center-University of Freiburg, Freiburg, Germany
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany
| | - Felix Kentischer
- Center for Geriatrics and Gerontology, University Medical Center Freiburg, Freiburg, Germany
| | - Eva Mennig
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| | - Sören Wagner
- Department of Anesthesiology, Klinikum Stuttgart, Stuttgart, Germany
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States
| | | | - Bernd R. Förstner
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Michael A. Rapp
- Department of Social and Preventive Medicine, University of Potsdam, Potsdam, Germany
| | - Christine A. F. von Arnim
- Department of Geriatrics, University Medical Center Göttingen, Georg August University, Göttingen, Germany
| | - Michael Denkinger
- Geriatric Center, Agaplesion Bethesda Clinic Ulm, Ulm, Germany
- Institute for Geriatric Research, Ulm University Medical Center, Ulm, Germany
| | - Gerhard W. Eschweiler
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
| | - Christine Thomas
- Geriatric Center and Department of Psychiatry and Psychotherapy, Tübingen University Hospital, Tübingen, Germany
- Department of Geriatric Psychiatry and Psychotherapy, Klinikum Stuttgart, Stuttgart, Germany
| |
Collapse
|
49
|
Devlin JW, Skrobik Y. What language conveys distress and reassurance? Intensive Care Med 2022; 48:599-601. [PMID: 35348819 PMCID: PMC8961086 DOI: 10.1007/s00134-022-06687-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/18/2022] [Indexed: 12/26/2022]
|
50
|
Prävention: postoperatives Delirium. Dtsch Med Wochenschr 2022. [DOI: 10.1055/a-1746-0859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|