Postoperative delirium following gastrointestinal surgery in elderly patients

Assessment and report of individual symptoms in studies of delirium in postoperative populations: a systematic review

OBJECTIVES

Delirium is most often reported as present or absent. Patients with symptoms falling short of the diagnostic criteria for delirium fall into 'no delirium' or 'control' groups. This binary classification neglects individual symptoms and may be hindering identification of the pathophysiology underlying delirium. This systematic review investigates which individual symptoms of delirium are reported by studies of postoperative delirium in adults.

METHODS

Medline, EMBASE and Web of Science databases were searched on 03 June 2021 and 06 April 2023. Two reviewers independently examined titles and abstracts. Each paper was screened in duplicate and conflicting decisions settled by consensus discussion. Data were extracted, qualitatively synthesised and narratively reported. All included studies were quality assessed.

RESULTS

These searches yielded 4,367 results. After title and abstract screening, 694 full-text studies were reviewed, and 62 deemed eligible for inclusion. This review details 11,377 patients including 2,049 patients with delirium. In total, 78 differently described delirium symptoms were reported. The most reported symptoms were inattention (N = 29), disorientation (N = 27), psychomotor agitation/retardation (N = 22), hallucination (N = 22) and memory impairment (N = 18). Notably, psychomotor agitation and hallucinations are not listed in the current Diagnostic and Statistical Manual for Mental Disorders-5-Text Revision delirium definition.

CONCLUSIONS

The 78 symptoms reported in this systematic review cover domains of attention, awareness, disorientation and other cognitive changes. There is a lack of standardisation of terms, and many recorded symptoms are synonyms of each other. This systematic review provides a library of individual delirium symptoms, which may be used to inform future reporting.

Comparison of the Effects of Desflurane and Sevoflurane on Variations in Salivary Melatonin and Sleep Disturbance After Total Knee Arthroplasty: A Single-center, Prospective, Randomized, Controlled, Open-label Study

PURPOSE

Anesthesia has been shown to disrupt the circadian rhythm. Recovery of the circadian rhythm after general anesthesia might help alleviate symptoms of insomnia and postoperative delirium. We hypothesized that recovery of the circadian rhythm is faster after total knee arthroplasty (TKA) with desflurane than with sevoflurane. This study compared the influence of sevoflurane versus desflurane anesthesia on the postoperative circadian rhythm of melatonin in adults undergoing TKA.

DESIGN

Single-center, prospective, randomized, controlled, open-label study.

METHODS

This study involved adult patients undergoing TKA at a university hospital in Japan from May 1, 2018 to December 31, 2019. The primary outcome of the study was the comparison of the effect of sevoflurane and desflurane on the circadian rhythm of salivary melatonin for 3 days postoperatively. The secondary outcomes were postoperative fatigue and sleep quality for 3 days postoperatively.

FINDINGS

Twenty-eight patients (American Society of Anesthesiologists physical status of I or II) were scheduled for TKA and randomized to receive sevoflurane (n = 14) or desflurane (n = 14) anesthesia. There was no significant difference in the melatonin concentration between the sevoflurane and desflurane groups. The salivary melatonin concentration after sevoflurane or desflurane anesthesia was significantly higher at 9:00 p.m. on a postoperative day (POD)0 and POD1 than on POD3 (P < .05). Patients in the desflurane group had significantly greater fatigue than those in the sevoflurane group at 7:00 a.m. and 12:00 p.m. on POD3 (P < .05). Patients in the sevoflurane group had a deeper sleep than those in the desflurane group on POD0 (P < .05). In the sevoflurane group, the sleep time during the night of POD2 was longer than that on POD0 (6.1 vs 4.2 hours, P < .05).

CONCLUSIONS

Under the current study conditions, desflurane was equivalent to sevoflurane in terms of the postoperative salivary melatonin concentration and sleep disturbance after TKA but not in terms of recovering the postoperative circadian rhythm.

Anesthetic Practice Trends and Perceptions Toward Postoperative Delirium: A Mixed-Methods Analysis

BACKGROUND

Delirium is the most common postoperative complication in older adults, though anesthesiologist awareness of delirium prevention guidelines-and associated practice trends-remains unknown.

METHODS

This was a convergent mixed-methods study, which simultaneously analyzed quantitative and qualitative data to determine delirium guideline awareness among anesthesiologists and practice patterns based on guideline recommendations. Quantitative data were abstracted from the Multicenter Perioperative Outcomes Group database for noncardiac surgery patients (2009-2020) aged 65 years and older. Linear trends were reported for select guideline-based delirium prevention recommendations via regression modeling. Anesthesiologists (n = 40) from a major academic center without a structured delirium reduction program on hospital wards were then surveyed regarding knowledge and practices with respect to postoperative delirium. For qualitative data, 3 focus groups were held to further discuss guideline awareness and identify challenges with delirium prevention.

RESULTS

Quantitative results demonstrated a significant decline in the proportion of cases with midazolam between 2009 and 2020, with the largest decrease observed with urologic surgeries (-3.9%/y; 95% confidence interval [CI], -4.2 to -3.6; P < .001). Use of regional anesthesia increased over this period, particularly with gynecologic surgeries (+2.3%/y; 95% CI, 1.2-3.4; P = .001). Anesthesiologist survey results revealed variable guideline awareness, as 21 of 39 (54%) respondents reported being aware of guidelines for anesthetic management of older adults. Importantly, unawareness of delirium management guidelines was the most frequently cited challenge (17 of 37, 46%) when caring for older adults. Finally, focus group participants were largely unaware of postoperative delirium guidelines. However, participants conveyed key barriers to delirium identification and prevention, including the unclear pathophysiology, nonmodifiable risk factors, and system-based hospital challenges. Participants also expressed a desire for decision-support systems, integrated within the perioperative workflow, that provide evidence-based recommendations for reducing delirium risk.

CONCLUSIONS

Perioperative practice trends are indicative of an improving environment for postoperative delirium. However, delirium guideline awareness remains variable among anesthesiologists, and key barriers continue to exist for identifying and preventing postoperative delirium.

Target-Controlled Anesthesia Reduces Postoperative Delirium in Spinal Surgical Patients: A Prospective Pilot Study

The aim of this pilot study was to examine the effect of combined target-controlled anesthesia and manually controlled anesthesia on the incidence of postoperative delirium (POD) in patients undergoing spinal surgery. All of the patients were enrolled before spinal surgery and divided into 2 groups at random: one group received combined sevoflurane target-controlled inhalation and sufentanil target-controlled infusion (S-S TCI group), whereas the other received combined manually controlled sevoflurane inhalation and sufentanil infusion (S-S MCI group). Data related to preoperative factors, perioperative factors, and postoperative data were retrospectively collected. Compared with the S-S MCI group, the dosage of vasoactive drugs after surgery, postoperative recovery time, time to cannula removal, and the incidence of POD were significantly decreased in the S-S TCI group (P &lt; 0.05). Overall, POD appeared in 81 patients (16.8%) by postoperative day 3. Multiple regression analysis showed that postoperative blood loss and manually controlled anesthesia were risk factors for POD in spinal surgery patients. Therefore, prophylactic blood transfusion and phenylephrine can reduce the incidence of POD in the presence of postoperative hypotension. Target-controlled anesthesia may improve the quality of anesthesia as well as reduce POD in spinal surgical patients. These results provide clinical evidence for improving the prevention, diagnosis, and management of POD.

Risk factors for postoperative delirium after colorectal operation

BACKGROUND

A clear understanding of risk factors for postoperative delirium helps in the selection of individuals who might benefit from targeted perioperative intervention. The aim of this study was to identify risk factors for postoperative delirium after colorectal operation for malignancy.

METHODS

All consecutive patients who underwent elective or emergency operation because of malignancy of the colon, sigmoid, or rectum between 2009 and 2012 were included in this study. Potential risk factors for postoperative delirium were selected based on previous studies. These candidate factors were analyzed using univariate and multivariate logistic regression analysis. Based on this analysis, odds ratios and 95% confidence intervals were estimated.

RESULTS

A total of 436 patients underwent an oncologic resection of the colon, sigmoid, or rectum. Postoperative delirium was observed in 45 (10.3%) patients. Patients with a delirium had a greater in-hospital mortality rate (8.9% vs 3.6%, P = .09), spent more days in the intensive care unit, and had a longer total hospital stay. Variables associated with postoperative delirium in univariate analyses were age, American Society of Anesthesiologists classification, blood transfusion, history of psychiatric disease, history of cerebrovascular disease, postoperative pain management, postoperative renal impairment, C-reactive protein levels, leukocyte blood count, and postoperative complications. Independent risk factors were history of psychiatric disease (odds ratio 8.38, 95% confidence interval: 1.50-46.82), age (odds ratio 4.01, 95% confidence interval; 1.55-10.37), and perioperative blood transfusion (odds ratio 2.37, 95% confidence interval; 1.11-5.06).

CONCLUSION

This study shows that postoperative delirium is a frequently encountered complication after colorectal operation. Three independent risk factors for postoperative delirium were identified (history of psychiatric disease, age, and perioperative transfusion) that may contribute to risk estimation in this patient population.

Incidence and risk factors of postoperative delirium in elderly patients who underwent laparoscopic surgery for colorectal cancer

BACKGROUND

The reported incidence of postoperative delirium (POD) in elderly patients ranges from 6 to 53 %. Several preoperative and operative factors have been reported as risk factors of POD.

AIM

The aim of this study was to determine the incidence of and risk factors for POD in patients with colorectal cancer who had undergone laparoscopic colorectal resection.

METHODS

A total of 311 consecutive patients aged 75 years and older who underwent laparoscopic surgery for colorectal cancer at our department from January 2008 to December 2013 were classified as delirious group (n = 44) and nondelirious group (n = 267). Short-term outcomes and risk factors for POD were analyzed.

RESULTS

POD was diagnosed in 14.1 % of elderly patients with colorectal cancer. Univariate analysis showed that older age, high American Society of Anesthesiology (ASA) score, performance status >2, low prognostic nutrition index (PNI), past history of delirium or dementia, operative approach, Organ/Space SSI, and cardiac or pulmonary disease were significantly associated with POD. Multivariate logistic regression analysis identified older age, past history of delirium or dementia, operative approach, and Organ/Space SSI as four independent risk factors for POD.

CONCLUSIONS

Our results suggest that the risk of POD is associated with older age, past history of delirium or dementia, operative approach, Organ/Space SSI.

Postoperative cognitive dysfunction: current developments in mechanism and prevention

Postoperative cognitive dysfunction (POCD) is a subtle disorder of thought processes, which may influence isolated domains of cognition and has a significant impact on patient health. The reported incidence of POCD varies enormously due to lack of formal criteria for the assessment and diagnosis of POCD. The significant risk factors of developing POCD mainly include larger and more invasive operations, duration of anesthesia, advanced age, history of alcohol abuse, use of anticholinergic medications, and other factors. The release of cytokines due to the systemic stress response caused by anesthesia and surgical procedures might induce the changes of brain function and be involved in the development of postoperative cognitive dysfunction. The strategies for management of POCD should be a multimodal approach involving close cooperation between the anesthesiologist, surgeon, geriatricians, and family members to promote early rehabilitation and avoid loss of independence in these patients.

Underrepresentation of patients with pre-existing cognitive impairment in pharmaceutical trials on prophylactic or therapeutic treatments for delirium: a systematic review

OBJECTIVE

Representation of hospitalized patients with pre-existing cognitive impairment in pharmaceutical delirium trials is important because these patients are at high risk for developing delirium. The aim of this systematic review is to investigate whether patients with cognitive impairment were included in studies on pharmacological prophylaxis or treatment of delirium and to explore the motivations for their exclusion (if they were excluded).

STUDY DESIGN

This study was a systematic review. A MEDLINE search was performed for publications dated from 1 January 1985 to 15 November 2012. Randomized and non-randomized controlled trials that investigated medication to prevent or treat delirium were included. The number of patients with cognitive impairment was counted, and if they were excluded, motivations were noted.

RESULTS

The search yielded 4293 hits, ultimately resulting in 31 studies that met the inclusion criteria. Of these, five studies explicitly mentioned the percentage of patients with cognitive impairment that were included. These patients comprised a total of 8% (n = 279 patients) of the 3476 patients included in all 31 studies. Ten studies might have included cognitively impaired patients but did not mention the exact percentage, and sixteen studies excluded all patients with cognitive impairment. The motivations for exclusion varied, but most were related to the influence of dementia on delirium.

CONCLUSION

The exclusion of patients with pre-existing cognitive impairment hampers the generalizability of the results of these trials and leaves clinicians with limited evidence about the pharmacological treatment of this group of vulnerable patients who have an increased risk of side effects.

Improving delirium care through early intervention: from bench to bedside to boardroom

Delirium is a complex neuropsychiatric syndrome that impacts adversely upon patient outcomes and healthcare outcomes. Delirium occurs in approximately one in five hospitalised patients and is especially common in the elderly and patients who are highly morbid and/or have pre-existing cognitive impairment. However, efforts to improve management of delirium are hindered by gaps in our knowledge and issues that reflect a disparity between existing knowledge and real-world practice. This review focuses on evidence that can assist in prevention, earlier detection and more timely and effective pharmacological and non-pharmacological management of emergent cases and their aftermath. It points towards a new approach to delirium care, encompassing laboratory and clinical aspects and health services realignment supported by health managers prioritising delirium on the healthcare change agenda. Key areas for future research and service organisation are outlined in a plan for improved delirium care across the range of healthcare settings and patient populations in which it occurs.

Delirium: a disturbance of circadian integrity?

Delirium is a serious neuropsychiatric syndrome of acute onset that occurs in approximately one in five general hospital patients and is associated with serious adverse outcomes that include loss of adaptive function, persistent cognitive problems and increased mortality. Recent studies indicate a three-domain model for delirium that includes generalised cognitive impairment, disturbed executive cognition, and disruption of behaviours that are under circadian control such as sleep-wake cycle and motor activity levels. As a consequence, attention has focused upon the possible role of the circadian timing system (CTS) in the pathophysiology of delirium. We explored this possibility by reviewing evidence that (1) many symptoms that occur in delirium are influenced by circadian rhythms, (2) many features of recognised circadian rhythm disorders are similar to characteristic features of delirium, (3) common risk factors for delirium are known to disrupt circadian systems, (4) physiological disturbances of circadian systems have been noted in delirious patients, and (5) positive effects in the treatment of delirium have been demonstrated for melatonin and related agents that influence the circadian timing system. A programme of future studies that can help to clarify the relevance of circadian integrity to delirium is described. Such work can provide a better understanding of the pathophysiology of delirium while also identifying opportunities for more targeted therapeutic efforts.

Incidence and causes of postoperative delirium in patients with esophageal cancer

AIM: To investigate the incidence and causes of postoperative delirium in patients with esophageal cancer.

METHODS: We conducted a retrospective cohort analysis of 124 patients who had undergone an esophagectomy at Tianjin Medical University General Hospital from January 2010 to December 2012. All quantitative data and all qualitative data were analyzed using Student's t test and Chi-square test, respectively.

RESULTS: Postoperative delirium developed in 60 (48.4%) of 124 patients. Elder age (P = 0.007), history of mental illness (P = 0.0001), longer period of time under mechanical ventilation after surgery (P = 0.0001), longer ICU stay after surgery (P = 0.0001), longer period of prohibiting drinking and eating from mouth after surgery (P = 0.0001), and occurrence of postoperative complications (P = 0.002) were significantly associated with the development of postoperative delirium.

CONCLUSION: The development of postoperative delirium in patients with esophageal cancer is a problem that should not be ignored. Causes of postoperative delirium include elder age, history of mental illness, longer periods of time under mechanical ventilation after surgery, longer postoperative ICU stays, longer periods of prohibiting drinking and eating from mouth after surgery, and occurrence of postoperative complications.

Postoperative delirium: a 76-year-old woman with delirium following surgery

Delirium (acute confusion) complicates 15% to 50% of major operations in older adults and is associated with other major postoperative complications, prolonged length of stay, poor functional recovery, institutionalization, dementia, and death. Importantly, delirium may be predictable and preventable through proactive intervention. Yet clinicians fail to recognize and address postoperative delirium in up to 80% of cases. Using the case of Ms R, a 76-year-old woman who developed delirium first after colectomy with complications and again after routine surgery, the diagnosis, prevention, and treatment of delirium in the postoperative setting is reviewed. The risk of postoperative delirium can be quantified by the sum of predisposing and precipitating factors. Successful strategies for prevention and treatment of delirium include proactive multifactorial intervention targeted to reversible risk factors, limiting use of sedating medications (especially benzodiazepines), effective management of postoperative pain, and, perhaps, judicious use of antipsychotics.

Review articles: postoperative delirium: acute change with long-term implications

Delirium is an acute change in cognition and attention, which may include alterations in consciousness and disorganized thinking. Although delirium may affect any age group, it is most common in older patients, especially those with preexisting cognitive impairment. Patients with delirium after surgery recover more slowly than those without delirium and, as a result, have increased length of stay and hospital costs. The measured incidence of postoperative delirium varies with the type of surgery, the urgency of surgery, and the type and sensitivity of the delirium assessment. Although generally considered a short-term condition, delirium can persist for months and is associated with poor cognitive and functional outcomes beyond the immediate postoperative period. In this article, we provide a guide to assess delirium risk preoperatively and to prevent, diagnose, and treat this common and morbid condition. Care improvements such as identifying delirium risk preoperatively; training surgeons, anesthesiologists, and nurses to screen for delirium; implementing delirium prevention programs; and developing standardized delirium treatment protocols may reduce the risk of delirium and its associated morbidity.

Risk factors for postoperative delirium after colorectal surgery for carcinoma

BACKGROUND AND AIM

Data regarding the incidence and risk factors for postoperative delirium (PD) after gastrointestinal surgery are heterogeneous because they include both benign and malignant disease. The aim of this study was to investigate the incidence and risk factors for PD in 100 consecutive patients over 65 years who underwent colorectal surgery for carcinoma.

METHODS

Pre-operative cognitive function was assessed using the Mini Mental State Examination. The onset of PD was diagnosed by the Confusion Assessment Methods administered to the patients every 12 h starting from the first postoperative day to discharge. The severity of PD was also evaluated with the Delirium Rating Scale. Different parameters: pre-, intra- and postoperative, were analyzed. Univariate and multivariate analyses were performed.

RESULTS

PD developed in 18% of patients. Univariate analysis revealed that advanced age, a history of PD, alcohol abuse, lower blood albumin concentration, intra-operative hypotension, elevated infusion volume and excessive blood loss were significantly related to the development of PD. On multivariate analysis, only lower levels of albumin, alcohol abuse, and hypotension were independent risk factors for PD.

CONCLUSIONS

These findings suggest that PD is a frequent complication after colorectal surgery for carcinoma. A model based on pre, intra and postoperative risk factors allows prediction of the patient's risk for developing PD in order to implement preventive measures for this complication.

Medical consultation and best practices for preoperative evaluation of elderly patients

Preoperative evaluation of elderly patients is an important component of surgical practice in the 21st century. It can offer a comprehensive geriatric evaluation and be a key element in decreasing postoperative morbidity and mortality in this unique population group. Advanced surgical and anesthetic techniques have contributed to an increasing number of elderly and sicker geriatric patients undergoing surgery. Elderly patients have limited physiologic reserve and pose many challenges in the perioperative setting, and a careful preoperative risk assessment aimed toward minimizing operative risks is essential. Advanced age increases the risk of developing complications post-surgery, but comorbidities are more important than age alone. General recommendations include avoiding drugs that increase the risk of delirium, ensuring appropriate hydration and calorie intake, minimizing bed rest, promoting ambulation, and early planning for discharge. Collaboration between surgeons and medical consultants aids in the identification of functional, cognitive, and nutritional deficits, provides structure for development and implementation of management plans, and promotes optimal patient outcome after surgical intervention in the elderly.

Early postoperative fever and the "routine" fever work-up: results of a prospective study

BACKGROUND

Fever in the postoperative period frequently results in a battery of diagnostic tests in search of an etiology. We sought to evaluate the incidence and utility of extensive postoperative fever evaluations in a teaching hospital setting.

MATERIALS AND METHODS

Prospective observational study of all adult patients undergoing in-patient general surgical procedures during a 13-mo period. Patients experiencing an early postoperative fever (>100.4° F in the first 72 h) had data collected on their evaluation, the yield of the diagnostic studies, and whether an infectious diagnosis was made.

RESULTS

Of 1032 surgical procedures, 245 (23.7%) patients experienced an early postoperative fever. One hundred patients (9.7%) underwent documented fever evaluation. Thirty-five (35%) had blood cultures with no positive results among elective surgery patients. Forty-six patients (46%) had urine cultures sent, of which four infections were diagnosed (8.9%). Fifty chest radiographs were performed, but the diagnosis of pneumonia was made by only three (6.0%). Ultimately, 18 febrile patients (18%) were diagnosed with an infectious source, in nine of these patients the physical exam and clinical picture accurately diagnosed the infection without need for further testing.

CONCLUSION

Early postoperative fever is a common event and rarely caused by an infection. A brief bedside evaluation has the highest yield for determining the fever etiology, and extensive evaluations with cultures and chest imaging have little to no benefit in patients admitted for elective surgery.

Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery

OBJECTIVE

The aim of this prospective study was to determine incidence, duration, and risk factors for postoperative delirium (PD) in elderly patients undergoing major abdominal surgery.

SUMMARY BACKGROUND DATA

The incidence and risk factors of PD after major abdominal surgery in elderly patients are not well documented.

METHODS

From May 2006 to May 2008, 118 patients aged 75 years or more without severe preoperative cognitive dysfunction (mini mental state examination score >10/30) and undergoing major elective abdominal surgery were included. The preoperative geriatric assessment battery consisted of 4 tests evaluating physical (instrumental activities of daily living and timed get up and go test score) and cognitive function (mini mental state examination score), and detecting the presence of an underlying depression (Short-GDS). After the operation, geriatric patients were assessed for PD by the Confusion Assessment Method. Univariate and multivariate analyses were used to determine risk factors for PD.

RESULTS

Overall, PD occurred in 28 patients (24%). Multivariate analysis showed that an American Society of Anesthesiologists status of 3-4 (P = 0.02), impaired mobility (timed get up and go test score >20 seconds) (P = 0.009) and postoperative tramadol administration (P = 0.0009) were risk factors for PD. The mortality rate was 14% in 28 patients with PD and 3.3% in 90 patients without PD (P = 0.051). The morbidity rate was 35.5% in 28 patients with PD and 32% in 90 patients without PD (NS). The mean hospital stay was 19 +/- 11 days for patients with PD and 14 +/- 8 for patients without PD (P = 0.01). Fifteen of 24 (62.5%) surviving patients with PD and 28 of 87 (32%) surviving patients without PD were discharged to geriatric rehabilitation unit (P = 0.007).

CONCLUSIONS

PD is a frequent and severe postoperative event in elderly patients after major abdominal surgery. A perioperative geriatric assessment should be recommended to patients with an American Society of Anesthesiologists status of 3-4 and preoperative impaired mobility to facilitate the management of PD. In these patients, the postoperative administration of tramadol should be avoided.

Risk factors for postoperative delirium in elderly patients with colorectal cancer

AIMS

The aim of this retrospective study is to examine risk factors for postoperative delirium in elderly patients with colorectal cancer.

METHODS

The study subjects were patients aged 71 years and older who underwent open surgery (OS) or laparoscopically assisted surgery (LAS) for colorectal cancer from January 2004 to December 2007. Preoperative evaluation, operative factors, morbidity, and mortality were analyzed using the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) and Prognostic Nutritional Index (PNI). Delirium was diagnosed by the Confusion Assessment Method (CAM).

RESULTS

Postoperative delirium was diagnosed in 10.9% of elderly patients with colorectal cancer. Age, American Society of Anesthesiologists (ASA) score, and PNI were significantly higher in patients with delirium than those without (P < 0.05, each). Postoperative delirium occurred more frequently in patients with encephalopathy than in those without (P = 0.003). Logistic regression analysis identified PNI and encephalopathy as two independent risk factors for postoperative delirium.

CONCLUSIONS

Preoperative evaluation of nutritional status is important in elderly patients with colorectal cancer in order to prevent postoperative delirium.

Postoperative delirium in the elderly surgical patient

Delirium is a common complication in the geriatric population following cardiac and noncardiac procedures. Postoperative delirium is a significant financial burden on the United States health care system and is independently associated with prolonged hospital stay, increased risk of early and long term mortality, increased physical dependence, and an increased rate of nursing home placement. The Confusion Assessment Method (CAM) is a bedside rating scale developed to assist nonpsychiatrically trained clinicians in the rapid and accurate diagnosis of delirium. The CAM has been adapted for use in ventilated intensive care unit (ICU) patients in the form of the CAM-ICU. The onset of delirium involves an interaction between predisposing and precipitating risk factors for delirium. The mainstay of delirium management is prevention. The approach involves control or elimination of modifiable risk factors. It is controversial whether anesthetic technique determines delirium. However, important modifiable risk factors under the anesthesiologist's control include adequate postoperative pain management, careful drug selection, and embracing and participating in a multidisciplinary care model for these complicated patients.

Postoperative delirium in elderly patients after major abdominal surgery

Background

The aim of this study was to investigate the occurrence of postoperative delirium (POD) in elderly patients undergoing major abdominal surgery and to identify factors associated with delirium in this population.

Methods

Data were collected prospectively from 51 patients aged 65 years or more. Delirium was diagnosed by the Confusion Assessment Method and from the medical records. The Mini Mental State Examination (MMSE) was used to identify cognitive impairment.

Results

POD occurred in 26 of 51 patients. Delirium lasted for 1–2 days in 14 patients (short POD group) and 3 days or more in 12 patients (long POD group). The latter patients had significantly greater intraoperative blood loss and intravenous fluid infusion, a higher rate of postoperative complications, a lower MMSE score on postoperative day 4 and a longer hospital stay than patients without POD. Patients in the short POD group were significantly older than those in the long POD group and those who did not develop delirium.

Conclusion

Approximately half of the elderly patients in this study developed POD. Bleeding was found to be an important risk factor for delirium.

[Digestive surgery in the elderly]

The dramatic increase in digestive surgery among patients of advanced age is the logical consequence of the aging population demographics in developed countries. Surgery in the aged is not fundamentally different, but it demands precise and tailored assessment and management of surgical indications and surgical and anesthetic techniques. Advanced age is not a contraindication to even major digestive surgery, but every effort must be made to avoid urgent operations by attention to pre-existing symptoms which are all-too-often neglected in the aged. Intensive care may help to shorten the hospital stay which should ideally occupy only a minor portion of the numbered days of the patient (whose life expectancy may be significantly longer than one may intuitively foresee).

Atherosclerosis is associated with delirium after coronary artery bypass graft surgery

OBJECTIVES

To investigate whether atherosclerosis of the ascending aorta, internal carotid arteries, and coronary arteries is predictive of postoperative delirium in subjects undergoing coronary artery bypass graft (CABG) surgery.

DESIGN

Prospective cohort study.

SETTING

Boston Veterans Affairs Healthcare System.

PARTICIPANTS

Thirty-six male veterans undergoing primary CABG surgery.

MEASUREMENTS

Subjects underwent Duplex ultrasound to assess stenosis in the internal carotid arteries. Information on the ascending aortic plaque, as assessed by transesophageal echocardiogram, and the number of coronary vessels bypassed was collected. To create an atherosclerosis score, the number of atherosclerotic areas was added. A validated delirium battery was administered to the subjects preoperatively and on postoperative Days 2 and 5.

RESULTS

Fifteen subjects (41.7%) developed delirium postoperatively. In bivariate analysis, carotid stenosis of 50% or more (relative risk (RR)=3.5, 95% confidence interval (CI)=1.5-8.1) and moderate-severe ascending aortic plaque (RR=2.9, 95% CI=1.0-8.5) were significantly associated with the development of delirium. There was a trend toward a significant association for three or more vessels bypassed (RR=9.6, 95% CI=0.6-145.3). After controlling for age, baseline cognition, and medical comorbidity, the atherosclerosis score was significantly associated with postoperative delirium (adjusted RR=2.7, 95% CI=1.1-6.8).

CONCLUSION

In this preliminary report, atherosclerosis in the carotid arteries, aorta, and coronary circulation is associated with the development of delirium after CABG surgery. Further investigation into atherosclerosis as a risk factor for delirium is warranted.

Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients

BACKGROUND

The prevalence of comorbidities and functional impairment among elderly patients may enhance the risk of operation-related complications, but the importance of these conditions in elderly patients undergoing thoracic surgery remains unclear.

METHODS

One hundred twenty patients >/= 60 years of age who underwent thoracic surgery were registered prospectively and examined. A comprehensive geriatric assessment (CGA) that evaluated such diverse areas as functional status (ie, performance status and activities of daily living [ADLs] using the Barthel index), comorbidity, nutrition (ie, body mass index, arm-muscle circumference, albumin level, transferrin level, lymphocyte count, and cholinesterase level), and cognitive function (ie, mini-mental state examination [MMSE] and negative emotions for operation) was performed in the 2 weeks before patients underwent the operation.

RESULTS

The diseases of the 120 patients were as follows: lung cancer, 85 patients; mediastinal tumor, 14 patients; bullas, 12 patients; and other diseases, 9 patients. Postoperative complications developed in 20 patients (16.7%). The patients with dependence for performing the ADLs, and dementia were more likely to develop postoperative complications (p = 0.041, and p = 0.0065, respectively). The patients who experienced longer operation times (ie, >/= 300 min; p = 0.018) were more likely to have complications. The incidence of prolonged air leak in the patients with malnutrition increased seven-fold (p = 0.045) and that of postoperative infectious diseases in those patients with obesity increased 24-fold (p = 0.0013), while all patients who developed delirium had low scores in the MMSE preoperatively (p = 0.0003). Using multiple logistic regression, the best model was obtained with a combination of MMSE (p = 0.031) and the Barthel index (p = 0.04). When the operation variables were added to this model, the operation time had the strongest effect (p = 0.016).

CONCLUSIONS

Dependence for the performance of ADLs and impaired cognitive conditions are important predictors of postoperative complications, especially when the operation time is long. CGA is necessary in addition to the conventional cardiopulmonary functional assessment in elderly patients.

Factors Associated With Postoperative Delirium After Thoracic Surgery

BACKGROUND

Postoperative delirium is an acute confusional state characterized by fluctuating consciousness and is associated with increased morbidity and mortality. We analyzed the incidence and risk factors of delirium following thoracic surgery.

METHODS

All patients (n = 432) who underwent thoracotomy or sternotomy from 1996 to 2003 were analyzed retrospectively. The diagnosis of postoperative delirium was based on Diagnostic and Statistical Manual of Mental Disorders- IV criteria.

RESULTS

Postoperative delirium developed in 23 patients (5.32%) between postoperative days 2 to 12 (mean, 4.4 +/- 2.6 days). There were 15 males and 8 females, with a mean age of 59.4 years (24 to 77 years). The delirium group was older (59.4 +/- 14.6 vs 51.3 +/- 15.5 years, p < 0.01) and had a longer operation time than the nondelirious group (5.34 +/- 1.58 vs 4.38 +/- 1.6 hours, p = 0.005). Morbidity and mortality rates were not significantly different between the two groups (56.5% vs 47.1%; 13.0% vs 3.66%, respectively). Univariate analysis showed that the older age, markedly abnormal postoperative levels of sodium, potassium, or glucose, sleep deprivation, operation time, and diabetes mellitus were risk factors (p < 0.05). According to multivariate analyses, four factors were selected as predictive risk factors: (1) markedly abnormal postoperative levels of sodium, potassium, or glucose (p = 0.038); (2) sleep deprivation (p = 0.05); (3) age (p = 0.033); and (4) operation time (p = 0.041).

CONCLUSIONS

Postoperative delirium may cause higher morbidity and mortality rates after thoracic surgery. Close postoperative follow-up and early identification of predisposing factors such as older age, sleep deprivation, abnormal postoperative levels of sodium, potassium, or glucose, and longer operation time can prevent occurrence of postoperative delirium.

Thoraxchirurgie im Alter

In the near future, over 40% of patients with lung cancer will be over 70 years old at the time their disease is diagnosed. Age per se, however, should not lead to the denial of a potentially curative surgical intervention. It has been shown that older patients (over 70 years), as well as patients over 80 years of age, may tolerate a lobectomy or even a pneumonectomy quite well. Most patients with lung cancer are present or former smokers and have underlying pulmonary problems, especially chronic obstructive lung disease. They are at high risk of both morbidity and mortality from surgery due to significant cardiovascular disease. The indications for surgical intervention should be based on reliable preoperative tumor staging and pulmonary assessment by an experienced interdisciplinary panel of physicians, taking into consideration the individual cardiopulmonary status of the patient. This assessment, combined with the American Society of Anesthesiologists risk classification and the overall clinical assessment by the surgeon, will provide the best available evidence for carefully weighing the benefits and risks of an operation. The responsibility for this assessment must be viewed-in the case of early stage lung cancer-in relation to the relative lack of alternative treatments for surgical intervention with comparable 5-year survival rates (>50%).

Risk factors for postoperative delirium after liver resection for hepatocellular carcinoma

We investigated risk factors for delirium in 100 patients who underwent liver resection for hepatocellular carcinoma. Postoperative delirium developed in 17 (17%). Univariate analysis revealed that advanced age (especially = 70 years old), a history of smoking, a decreased serum albumin concentration (especially < 3.8 g/dl), advanced cancer stage (II-IV), major hepatectomy, prolonged operating time, and large intraoperative blood loss were possible risk factors for postoperative delirium. When patients' preoperative condition and laboratory test results were subjected to multivariate analysis, only advanced age [odds ratio (OR) 1.201; confidence interval (CI) 1.063-1.357] and a decreased serum albumin concentration (OR 0.151; CI 0.025-0.900) were independent risk factors for the delirium. The percentages of patients with high aspartate and alanine aminotransferase activities, a high indocyanine green retention rate at 15 minutes, a low platelet count, and advanced cancer stage (II-IV) were higher in patients with a low (< 3.8 g/dl), rather than high (= 3.8 g/dl) serum albumin concentration. These findings indicate that multiple factors, including advanced age, impaired liver function, and advanced cancer stage, affect the development of postoperative delirium after liver resection for hepatocellular carcinoma.

Encephalopathy and Stroke After Coronary Artery Bypass Grafting

Both stroke and encephalopathy are associated with significantly longer lengths of stay in the hospital and with significantly higher rates of mortality. Those at risk for either stroke or encephalopathy, or both of these adverse outcomes after surgery, can be identified prior to surgery using information available to physicians. For those at higher risk for these outcomes, we suggest the following: 1) An imaging study of the brain, performed prior to surgery, may indicate the degree of cerebrovascular disease. At present we do not have this information on most patients. 2) The status of arteriosclerotic disease of the aorta should be determined prior to surgery or at the time of surgery. 3) For those with significant aortic and cerebrovascular disease, alternatives to the conventional ways of performing coronary artery bypass grafting (CABG) should be considered. These alternatives include percutaneous transluminal coronary angioplasty, off-pump surgery, and CABG using filters or inputs from the pump that selectively protect the brain.

Predicting delirium after vascular surgery: a model based on pre- and intraoperative data

OBJECTIVE

The aim of the study was to determine pre- and intraoperative risk factors for the development of postoperative delirium among patients undergoing aortic, carotid, and peripheral vascular surgery to predict the risk for postoperative delirium.

SUMMARY BACKGROUND DATA

Although postoperative delirium after vascular surgery is a frequent complication and is associated with the need for more inpatient hospital care and longer length of hospital stay, little is known about risk factors for delirium in patients undergoing vascular surgery.

METHODS

Pre-, intra-, and postoperative data were prospectively collected, including the first 7 postoperative days with daily follow-up by a surgeon and a psychiatrist of 153 patients undergoing elective vascular surgery. Delirium (Diagnostic and statistical Manual of Mental Disorders IV) was diagnosed by the psychiatrist. Multivariate linear logistic regression and a cross validation analysis were performed to find a set of parameters to predict postoperative delirium.

RESULTS

Sixty patients (39.2%) developed postoperative delirium. The best set of predictors included the absence of supraaortic occlusive disease and hypercholesterinemia, history of a major amputation, age over 65 years, a body size of less than 170 cm, preoperative psychiatric parameters and intraoperative parameters correlated to increased blood loss. The combination of these parameters allows the estimation of an individual patients' risk for postoperative delirium already at the end of vascular surgery with an overall accuracy of 69.9%.

CONCLUSIONS

Postoperative delirium after vascular surgery is a frequent complication. A model based on pre- and intraoperative somatic and psychiatric risk factors allows prediction of the patient's risk for developing postoperative delirium.

Reversible dementia in patients with chronic subdural hematomas

OBJECT

Neuropsychiatric changes following surgery for chronic subdural hematomas (CSDHs) were analyzed in 26 patients (21 men and five women) by using the Mini-Mental State Examination (MMSE) and the Hasegawa Dementia Scale-Revised (HDS-R) to determine factors that potentially contribute to neuropsychiatric recovery.

METHODS

Burr hole irrigation was performed in every patient to treat the CSDH. The patients' profiles, including age and sex, neuroimaging findings (such as hematoma volume and thickness, as well as midline shift), and preoperative and postoperative scores on the MMSE, HDS-R, and activities of daily living (ADL) scale were recorded. According to preoperative MMSE scores, eight patients (30.8%) were classified as mentally healthy and 18 (69.2%) as suffering from dementia before surgery. Nine of the 18 patients with dementia recovered to a normal psychological state following surgery. Surgery improved not only the patients' independence in ADL (p = 0.0026), but also their neuropsychiatric functions such as orientation and calculation, as estimated by scores on the MMSE (p = 0.0002) and the HDS-R (p = 0.0008). Factors affecting neuropsychiatric status on admission were midline shift (p = 0.0398) and ADL score (p = 0.0124); factors that could be used to predict neuropsychiatric recovery after surgery were patient age (p = 0.0027) and ADL score (p = 0.0193). The results of a logistic regression analysis demonstrated that significant predictors of neuropsychiatric recovery after surgery include the following: patient age (p = 0.0049, odds ratio [OR] = 0.842) and preoperative ADL (p = 0.0056, OR = 0.471), MMSE (p < 0.0001, OR = 1.895), and HDS-R (p = 0.0073, OR = 1.303) scores. Results of subgroup analyses demonstrated that patients younger than 74 years of age and those who had preoperative scores lower than 5 on the converted ADL scale, higher than 10 on the MMSE, or higher than 9 on the HDS-R on admission were found to have a significantly better recovery of neuropsychiatric functions after surgery.

CONCLUSIONS

Dementia is reversible in many patients with CSDH, and surgery can improve not only independence in ADL, but also neuropsychiatric functions. Patients who are younger and/or those who have lower preoperative ADL scores and/or higher preoperative MMSE or HDS-R scores will achieve a good recovery with regard to neuropsychiatric functions after surgery. Estimations of neuropsychiatric function based on MMSE and HDS-R scores were found to be useful in predicting functional outcomes in patients with CSDH.

Postoperative delirium and melatonin levels in elderly patients

BACKGROUND

Melatonin, a hormone produced in the pineal gland, is involved in circadian rhythms and the sleep-wake cycle. Postoperative delirium is encountered frequently in elderly patients after major surgery; whether changes in the pattern of melatonin secretion are associated is unclear.

METHODS

Plasma samples were obtained every 2 hours from 19 patients without delirium and 10 with delirium after major abdominal surgery. Postoperative delirium was determined using the Confusion Assessment Method in the Practice Guideline of the American Psychiatric Association.

RESULTS

All patients without delirium showed nearly identical preoperative and postoperative melatonin secretion for 24 hours, although peak values were significantly lower in patients more than 80 years old (7.2 +/- 2.3 pg/mL) than in patients younger than 80 years (24.4 +/- 4.1 pg/mL, P = 0.022). Patients with delirium showed two different abnormal postoperative patterns: in 5 patients without complications, melatonin levels were lower than preoperative values (11.0 +/- 5.8 versus 6.5 +/- 4.2 pg/mL, P = 0.079); and in 5 patients with complications, melatonin levels were markedly increased (21.1 +/- 4.5 versus 58.8 +/- 12.4 pg/mL, P = 0.043).

CONCLUSIONS

Abnormal melatonin secretion may be involved in postoperative sleep disturbances, which triggered delirium in elderly patients.

Minimizing perioperative adverse events in the elderly

Elderly patients still have the highest postoperative mortality and morbidity rate in the adult surgical population. Preoperative clinical assessment to detect patients at high risk of postoperative events, and specific intraoperative and postoperative anaesthesia management are important to minimize postoperative adverse events in the elderly.

Postoperative delirium in patients with chronic lower limb ischaemia: what are the specific markers?

OBJECTIVES

we determined the incidence and specific markers of postoperative delirium in elderly patients with chronic lower limb ischaemia.

PATIENTS AND METHODS

since April, 1995, 110 patients aged 60 years or older (mean: 71.6+/-6.6 years) who underwent bypass surgery were assessed regarding aetiological factors of delirium: age, sex, dementia, body-mass index, hypertension, diabetes, cerebral disease, laboratory test results, severity of limb ischaemia, type of arterial occlusion, operative time, and blood transfusion.

RESULTS

discriminant analysis showed statistical significance in the following five variables: age >/=70 years; critical limb ischaemia (and/or ankle pressure <40 mmHg); dementia; duration of operation >/=7 hours; low serum albumin. The overall percentage of cases correctly classified was 78.2% (Wilks>> Lambda=0.695, p<0.001); the standardized regression coefficients of the five variables were 0.648, 0.500, 0.329, 0.218, and 0.200, respectively. In logistic regression, the regression coefficients for old age and critical limb ischaemia were 2.646 (14.1 of odds ratio; 95% confidence interval, 2.7-72.0) and 1.337 (3.8; 1.3-10.9), respectively.

CONCLUSIONS

the incidence of postoperative delirium in elderly patients with chronic lower-limb ischaemia was as high as 42.3%, and an age of over 70 years and critical limb ischaemia were identified as specific markers, with 14.1 times and 3.8 times the odds of suffering from delirium after bypass surgery.

Cognitive decline after major noncardiac operations: a preliminary prospective study

BACKGROUND

Cardiac operations frequently are complicated by postoperative cognitive decline. Less common and less studied is postoperative cognitive decline after noncardiac surgery, so we determined its incidence, severity, and possible predictors.

METHODS

Twenty-nine patients who had thoracic and vascular procedures were studied. A neurocognitive test battery was administered preoperatively and 6 to 12 weeks postoperatively. A change score (preoperative minus postoperative) was calculated for each measure in each individual. Cognitive deficit (a measure of incidence) was defined as a 20% decrement in 20% or more of the completed tests. The average scores of all tests and the average decline (a measure of severity) were determined.

RESULTS

The incidence of cognitive deficit was 44.8%. Overall the severity of the decline was an average of 15% decline. In the 44.8% of patients who had cognitive deficit, the severity was 24.7%. Multivariable predictors of cognitive decline were age (for incidence and severity) and years of education (for severity).

CONCLUSIONS

Cognitive decline after noncardiac operations is a frequent complication of surgical procedures. The severity could preclude successful return to a preoperative lifestyle.