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Khan SH, Perkins AJ, Jawaid S, Wang S, Lindroth H, Schmitt RE, Doles J, True JD, Gao S, Caplan GA, Twigg HL, Kesler K, Khan BA. Serum proteomic analysis in esophagectomy patients with postoperative delirium: A case-control study. Heart Lung 2024; 63:35-41. [PMID: 37748302 PMCID: PMC10843392 DOI: 10.1016/j.hrtlng.2023.09.009] [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: 07/07/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Postoperative delirium occurs in up to 80% of patients undergoing esophagectomy. We performed an exploratory proteomic analysis to identify protein pathways that may be associated with delirium post-esophagectomy. OBJECTIVES Identify proteins associated with delirium and delirium severity in a younger and higher-risk surgical population. METHODS We performed a case-control study using blood samples collected from patients enrolled in a negative, randomized, double-blind clinical trial. English speaking adults aged 18 years or older, undergoing esophagectomy, who had blood samples obtained were included. Cases were defined by a positive delirium screen after surgery while controls were patients with negative delirium assessments. Delirium was assessed using Richmond Agitation Sedation Scale and Confusion Assessment Method for the Intensive Care Unit, and delirium severity was assessed by Delirium Rating Scale-Revised-98. Blood samples were collected pre-operatively and on post-operative day 1, and discovery proteomic analysis was performed. Between-group differences in median abundance ratios were reported using Wilcoxon-Mann-Whitney Odds (WMWodds1) test. RESULTS 52 (26 cases, 26 controls) patients were included in the study with a mean age of 64 (SD 9.6) years, 1.9% were females and 25% were African American. The median duration of delirium was 1 day (IQR: 1-2), and the median delirium/coma duration was 2.5 days (IQR: 2-4). Two proteins with greater relative abundance ratio in patients with delirium were: Coagulation factor IX (WMWodds: 1.89 95%CI: 1.0-4.2) and mannosyl-oligosaccharide 1,2-alpha-mannosidase (WMWodds: 2.4 95%CI: 1.03-9.9). Protein abundance ratios associated with mean delirium severity at postoperative day 1 were Complement C2 (Spearman rs = -0.31, 95%CI [-0.55, -0.02]) and Mannosyl-oligosaccharide 1,2-alpha-mannosidase (rs = 0.61, 95%CI = [0.29, 0.81]). CONCLUSIONS We identified changes in proteins associated with coagulation, inflammation, and protein handling; larger, follow-up studies are needed to confirm our hypothesis-generating findings.
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Affiliation(s)
- Sikandar H Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA.
| | - Anthony J Perkins
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Samreen Jawaid
- Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA
| | - Sophia Wang
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Heidi Lindroth
- Department of Nursing, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Rebecca E Schmitt
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason Doles
- Department of Anatomy, Cell Biology and Physiology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jason D True
- Department of Biology, Ball State University, Muncie, Indiana, USA
| | - Sujuan Gao
- Department of Biostatistics and Health Data Science, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gideon A Caplan
- Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia; Department of Geriatric Medicine, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Homer L Twigg
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kenneth Kesler
- Department of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Babar A Khan
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA; Indiana University Center for Aging Research, Regenstrief Institute, Indianapolis, Indiana, USA; Indiana University Center of Health Innovation and Implementation Science, Indianapolis, Indiana, USA
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Chen J, Chen J, Hu J, Huang R, Shen L, Gu H, Chai X, Wang D. Cigarette smoking is linked to an increased risk of delirium following arthroplasty in patients suffering from osteoarthritic pain. CNS Neurosci Ther 2023; 29:3854-3862. [PMID: 37334739 PMCID: PMC10651961 DOI: 10.1111/cns.14306] [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: 02/10/2023] [Revised: 04/03/2023] [Accepted: 05/30/2023] [Indexed: 06/20/2023] Open
Abstract
AIMS Postoperative delirium (POD) is a common postoperative complication, and the potential relationship between cigarette smoking and POD is still unclear. The current study evaluated the relationship between preoperative smoking status in patients suffering from osteoarthritic pain and POD after total knee arthroplasty (TKA). METHODS A total of 254 patients who had undergone unilateral TKA were enrolled between November 2021 and December 2022, with no gender limitation. Preoperatively, patients' visual analog scale (VAS) scores at rest and during movement, hospital anxiety and depression (HAD) scores, pain catastrophizing scale (PCS) scores and smoking status were collected. The primary outcome was the incidence of POD, which was evaluated by the confusion assessment method (CAM). RESULTS A total of 188 patients had complete datasets for final analysis. POD was diagnosed in 41 of 188 patients (21.8%) who had complete data for analysis. The incidence of smoking was significantly higher in Group POD than in Group Non-POD (22 of 41 patients [54%] vs. 47 of 147 patients [32%], p < 0.05). The postoperative hospital stays were also longer than those of Group Non-POD (p < 0.001). Multiple logistic regression analysis showed that preoperative smoking (OR: 4.018, 95% CI: 1.158-13.947, p = 0.028) was a risk factor for the occurrence of POD in patients with TKA. The length of hospital stay was correlated with the occurrence of POD. CONCLUSIONS Our findings suggest that patients who smoked preoperatively were at increased risk of developing POD following TKA.
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Affiliation(s)
- Jie‐ru Chen
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Jia‐qi Chen
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Ji‐cheng Hu
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Run‐sheng Huang
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Liang Shen
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Hai Gu
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Xiao‐qing Chai
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
| | - Di Wang
- Pain Clinic, Department of Anesthesiology, First Affiliated Hospital of USTCDivision of Life Sciences and Medicine, University of Science and Technology of ChinaHefeiChina
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Yan E, Veitch M, Saripella A, Alhamdah Y, Butris N, Tang-Wai DF, Tartaglia MC, Nagappa M, Englesakis M, He D, Chung F. Association between postoperative delirium and adverse outcomes in older surgical patients: A systematic review and meta-analysis. J Clin Anesth 2023; 90:111221. [PMID: 37515876 DOI: 10.1016/j.jclinane.2023.111221] [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: 01/27/2023] [Revised: 07/10/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
STUDY OBJECTIVE To assess the incidence of postoperative delirium and its outcomes in older non-cardiac surgical patients. DESIGN A systematic review and meta-analysis with multiple databases searched from inception to February 22, 2022. SETTING Postoperative assessments. PATIENTS Non-cardiac and non-neurological surgical patients aged ≥60 years with and without postoperative delirium. Included studies must report ≥1 postoperative outcome. Studies with a small sample size (N < 100 subjects) were excluded. MEASUREMENTS Outcomes comprised the pooled incidence of postoperative delirium and its postoperative outcomes, including mortality, complications, unplanned intensive care unit admissions, length of stay, and non-home discharge. For dichotomous and continuous outcomes, OR and difference in means were computed, respectively, with a 95% CI. MAIN RESULTS Fifty-four studies (20,988 patients, 31 elective studies, 23 emergency studies) were included. The pooled incidence of postoperative delirium was 19% (95% CI: 16%, 23%) after elective surgery and 32% (95% CI: 25%, 39%) after emergency surgery. In elective surgery, postoperative delirium was associated with increased mortality at 1-month (OR: 6.60; 95% CI: 1.58, 27.66), 6-month (OR: 5.69; 95% CI: 2.33, 13.88), and 1-year (OR: 2.87; 95% CI: 1.63, 5.06). The odds of postoperative complications, unplanned intensive care unit admissions, prolonged length of hospital stay, and non-home discharge were also higher in delirium cases. In emergency surgery, patients with postoperative delirium had greater odds of mortality at 1-month (OR: 3.56; 95% CI: 1.77, 7.15), 6-month (OR: 2.60; 95% CI: 1.88, 3.61), and 1-year (OR: 2.30; 95% CI: 1.77, 3.00). CONCLUSIONS Postoperative delirium was associated with higher odds of mortality, postoperative complications, unplanned intensive care unit admissions, length of hospital stay, and non-home discharge. Prevention and perioperative management of delirium may optimize surgical outcomes.
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Affiliation(s)
- Ellene Yan
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Matthew Veitch
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Aparna Saripella
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Yasmin Alhamdah
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - Nina Butris
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada
| | - David F Tang-Wai
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Maria Carmela Tartaglia
- Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada; Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Mahesh Nagappa
- Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Marina Englesakis
- Library & Information Services, University Health Network, Toronto, ON, Canada
| | - David He
- Department of Anesthesiology and Pain Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, Temerty Faculty of Medicine, University of Toronto, ON, Canada.
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Guo Y, Ji H, Liu J, Wang Y, Liu J, Sun H, Fei Y, Wang C, Ma T, Han C. Development and Validation of a Delirium Risk Prediction Model for Elderly Patients Undergoing Elective Orthopedic Surgery. Neuropsychiatr Dis Treat 2023; 19:1641-1654. [PMID: 37497306 PMCID: PMC10368119 DOI: 10.2147/ndt.s416854] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/14/2023] [Indexed: 07/28/2023] Open
Abstract
Purpose This study aimed to develop and validate a post-operative delirium (POD) nomogram in a population of elderly patients undergoing elective orthopedic surgery. Patients and Methods A predictive model was developed based on a training dataset of 474 elderly patients undergoing elective orthopedic surgery from March 2021 to May 2022. POD was identified using the Confusion Assessment Methods (CAM). The least absolute shrinkage and selection operator (LASSO) method was used to screen risk factors, and prediction models were created by combining the outcomes with logistic regression analysis. We employ bootstrap validation for internal validation to examine the model's repeatability. The results were validated using a prospective study on 153 patients operated on from January 2022 to May 2022 at another institution. Results The predictors in the POD nomogram included age, the Mini-Mental State Examination(MMSE), sleep disorder, neurological disorders, preoperative serum creatinine (Pre-SCR), and ASA classification. The c-index of the model was 0.928 (95% confidence interval 0.898 ~ 0.957) and the bootstrap validation still achieved a high c-index of 0.912. The c-index of the external validation was 0.921. The calibration curve for the diagnostic probability showed good agreement between prediction by nomogram and actual observation. Conclusion By combining preoperative and intraoperative clinical risk factors, we created a POD risk nomogram to predict the probability of POD in elderly patients who undergo elective orthopedic surgery. It could be a tool for guiding individualized interventions.
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Affiliation(s)
- Yaxin Guo
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Haiyan Ji
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Junfeng Liu
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Yong Wang
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Jinming Liu
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Hong Sun
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Yuanhui Fei
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Chunhui Wang
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Tieliang Ma
- Central Laboratory, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
| | - Chao Han
- Department of Anesthesiology, the Affiliated Yixing Hospital of Jiangsu University, Yixing, Jiangsu, 214200, People’s Republic of China
- Yixing Clinical College, Medical College of Yangzhou University, Yixing, Jiangsu, 214200, People’s Republic of China
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Park JW, Ha YC, Kim JW, Kim TY, Kim JW, Baek SH, Lee YK, Koo KH. The Korean hip fracture registry study. BMC Musculoskelet Disord 2023; 24:449. [PMID: 37268896 DOI: 10.1186/s12891-023-06546-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The purpose of the Korean Hip Fracture Registry (KHFR) Study is to establish a nationwide, hospital-based prospective cohort study of adults with hip fracture to explore the incidence and risk factors of second osteoporotic fractures for a Fracture Liaison Service (FLS) model. METHODS The KHFR, a prospective multicenter longitudinal study, was launched in 2014. Sixteen centers recruited participants who were treated for hip fracture. The inclusion criteria were patients, who were treated for proximal femur fracture due to low-energy trauma and aged 50 or more at the time of injury. Until 2018, 5,841 patients were enrolled in this study. Follow-up surveys were conducted annually to determine occurrence of second osteoporotic fracture, and 4,803 participants completed at least one follow-up survey. DISCUSSION KHFR is a unique resource of individual level on osteoporotic hip fracture with radiological, medical, and laboratory information including DXA (dual energy x-ray absorptiometry), bone turnover marker, body composition, and hand grip strength for future analyses for FLS model. Modifiable factors for mortality after hip surgery is planned to be identified with nutritional assessment and multi-disciplinary interventions from hospitalization to follow-ups. The proportions of femoral neck, intertrochanteric, and subtrochanteric fractures were 517 (42.0%), 730 (53.6%), and 60 (4.4%), respectively, from 2014 to 2016, which was similar in other studies. Radiologic definition of atypical subtrochanteric fracture was adopted and 17 (1.2%) fractures among 1,361 proximal femoral fractures were identified. Internal fixation showed higher reoperation rate compared to arthroplasty in unstable intertrochanteric fractures (6.1% vs. 2.4%, p = 0.046) with no significant difference in mortality. The KHFR plans to identify outcomes and risk factors associated with second fracture by conducting a 10-year cohort study, with a follow-up every year, using 5,841 baseline participants. TRIAL REGISTRATION Present study was registered on Internet-based Clinical Research and Trial management system (iCReaT) as multicenter prospective observational cohort study (Project number: C160022, Date of registration: 22th, Apr, 2016).
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Affiliation(s)
- Jung-Wee Park
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yong-Chan Ha
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul, South Korea
| | - Jin-Woo Kim
- Department of Orthopaedic Surgery, Nowon Eulji Medical Center, Seoul, South Korea
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Konkuk University School of Medicine, Seoul, South Korea
| | - Ji Wan Kim
- Department of Orthopaedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung-Hoon Baek
- Department of Orthopedic Surgery, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Young-Kyun Lee
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Kyung-Hoi Koo
- Department of Orthopaedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
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Zhao S, Sun T, Zhang J, Chen X, Wang X. Risk factors and prognosis of postoperative delirium in nonagenarians with hip fracture. Sci Rep 2023; 13:2167. [PMID: 36750657 PMCID: PMC9905086 DOI: 10.1038/s41598-023-27829-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 01/09/2023] [Indexed: 02/09/2023] Open
Abstract
Hip fractures in nonagenarians is one of the great challenges for patients of this age, the family and the larger society. The purpose of this study was to investigate the risk factors and prognosis of postoperative delirium in nonagenarians with hip fracture. 199 Eligible patients were enrolled. Confusion Assessment Method (CAM) were used to identify the delirium. Logistic regressions were used to investigate the effect of 18 pre-existing conditions on postoperative delirium. Prognosis of postoperative delirium in nonagenarians with hip fracture were also be evaluated. The results indicated the following: (1) the prevalence of postoperative delirium among nonagenarians with hip fracture was 28.1% (56 of 199); (2) coexisting disease ≥ 4 (OR = 5.355, 95% CI = 1.394-9.074, P = 0.007), longer admission to operating time (OR = 1.514, 95% CI = 1.247-1.837, P = 0.000), and general anesthesia (OR = 2.086, 95% CI = 1.804-7.968, P = 0.032) were independent risk factors for postoperative delirium in nonagenarians with hip fracture; (3) nonagenarians with postoperative delirium had a predominantly high burden of perioperative complications, long length of stay, and postoperative mortality at 30 days follow-up and 1 year follow-up than the patients without postoperative delirium. The results could enable clinicians to improve outcome after operation in nonagenarians with hip fracture.
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Affiliation(s)
- Shengjie Zhao
- Department of Neurorehabilitation, China Rehabilitation Research Center, Capital Medical University School of Rehabilitation Medicine, No. 10, JiaoMenBei Lu, Beijing, 100068, China
| | - Tiansheng Sun
- Department of Orthopedics, The Seventh Medical Center of China General Hospital of People's Liberation Army, Beijing, 100700, China
| | - Jianzheng Zhang
- Department of Orthopedics, The Seventh Medical Center of China General Hospital of People's Liberation Army, Beijing, 100700, China
| | - Xiaobin Chen
- Department of Orthopedics, The Seventh Medical Center of China General Hospital of People's Liberation Army, Beijing, 100700, China
| | - Xiaowei Wang
- Department of Orthopedics, The Seventh Medical Center of China General Hospital of People's Liberation Army, Beijing, 100700, China.
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Ormseth CH, LaHue SC, Oldham MA, Josephson SA, Whitaker E, Douglas VC. Predisposing and Precipitating Factors Associated With Delirium: A Systematic Review. JAMA Netw Open 2023; 6:e2249950. [PMID: 36607634 PMCID: PMC9856673 DOI: 10.1001/jamanetworkopen.2022.49950] [Citation(s) in RCA: 41] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
IMPORTANCE Despite discrete etiologies leading to delirium, it is treated as a common end point in hospital and in clinical trials, and delirium research may be hampered by the attempt to treat all instances of delirium similarly, leaving delirium management as an unmet need. An individualized approach based on unique patterns of delirium pathophysiology, as reflected in predisposing factors and precipitants, may be necessary, but there exists no accepted method of grouping delirium into distinct etiologic subgroups. OBJECTIVE To conduct a systematic review to identify potential predisposing and precipitating factors associated with delirium in adult patients agnostic to setting. EVIDENCE REVIEW A literature search was performed of PubMed, Embase, Web of Science, and PsycINFO from database inception to December 2021 using search Medical Subject Headings (MeSH) terms consciousness disorders, confusion, causality, and disease susceptibility, with constraints of cohort or case-control studies. Two reviewers selected studies that met the following criteria for inclusion: published in English, prospective cohort or case-control study, at least 50 participants, delirium assessment in person by a physician or trained research personnel using a reference standard, and results including a multivariable model to identify independent factors associated with delirium. FINDINGS A total of 315 studies were included with a mean (SD) Newcastle-Ottawa Scale score of 8.3 (0.8) out of 9. Across 101 144 patients (50 006 [50.0%] male and 49 766 [49.1%] female patients) represented (24 015 with delirium), studies reported 33 predisposing and 112 precipitating factors associated with delirium. There was a diversity of factors associated with delirium, with substantial physiological heterogeneity. CONCLUSIONS AND RELEVANCE In this systematic review, a comprehensive list of potential predisposing and precipitating factors associated with delirium was found across all clinical settings. These findings may be used to inform more precise study of delirium's heterogeneous pathophysiology and treatment.
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Affiliation(s)
- Cora H. Ormseth
- Department of Emergency Medicine, University of California, San Francisco
| | - Sara C. LaHue
- Department of Neurology, University of California, San Francisco
| | - Mark A. Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | | | - Evans Whitaker
- University of California, San Francisco, School of Medicine
| | - Vanja C. Douglas
- Department of Neurology, University of California, San Francisco
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Tobita M, Fanchiang SP, Saldivar A, Taylor S, Jordan B. Complex Hallucinations in Hospitalized Rehabilitation Patients With COVID-19. Arch Rehabil Res Clin Transl 2022; 4:100234. [PMID: 36277732 PMCID: PMC9574548 DOI: 10.1016/j.arrct.2022.100234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Objectives To explore the characteristics of hallucinations in hospitalized rehabilitation patients with COVID-19. Design Retrospective review using medical records of patients with COVID-19 and admitted to the acute inpatient rehabilitation unit (ARU). Setting A public hospital in southern California, specializing in rehabilitation medicine. Participants: Patients with COVID-19 and hallucinations who were consecutively admitted from January 1st to April 30th, 2021. Interventions Not applicable. Main Outcome Measures Types and themes of hallucinations. Results Eight of the 37 patients (21.6%) admitted to the ARU with COVID-19 exhibited hallucinations. All were Hispanic and 7 of them were men; their average age was 56.5 (range: 38-71). Seven patients had COVID-19 pneumonia and 1 developed respiratory distress secondary to Guillain-Barre Syndrome. One patient had posterior reversible encephalopathy syndrome. The average length of stay in the intensive care unit (ICU) was 31.3 days (range: 8-48). Most of the hallucinations occurred during their ICU stay and 2 continued to their ARU stay. All recalled details of hallucinations with 7 exhibiting visual hallucinations, consistent with peduncular hallucinosis with or without auditory and/or tactile components. One patient experienced tactile hallucinations. The themes of hallucinations identified to reflect the contents of the hallucinations were patients' comfort-seeking, fearfulness, and seeing deceased family members. All patients had impaired cognition at the ARU admission but improved at discharge. Four patients had depressed mood/anxiety and 1 had depressed mood alone but without a history of psychiatric illness. ICU delirium was documented in 5 patients. The negative experience of hallucinations seemed to affect their participation of the ARU stay. Conclusions More than 20% of patients with COVID-19 who were transferred to attend inpatient rehabilitation exhibited hallucinations. It remains uncertain if these hallucinations were related to the SARS-CoV-2 infection. Multidisciplinary rehabilitation team should be aware to support patients with COVID-19 who experience hallucinations.
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Affiliation(s)
- Mari Tobita
- Rancho Los Amigos National Rehabilitation Center, Department of Health Services, County of Los Angeles, Downey, CA,Rancho Research Institute, Downey, CA,Corresponding author Mari Tobita, MD, 7601 E Imperial Highway, Downey, CA 90242
| | - Shan-Pin Fanchiang
- Rancho Los Amigos National Rehabilitation Center, Department of Health Services, County of Los Angeles, Downey, CA,Rancho Research Institute, Downey, CA,Department of Internal Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA
| | - Aida Saldivar
- Rancho Los Amigos National Rehabilitation Center, Department of Health Services, County of Los Angeles, Downey, CA
| | - Sarah Taylor
- Rancho Los Amigos National Rehabilitation Center, Department of Health Services, County of Los Angeles, Downey, CA
| | - Barry Jordan
- Rancho Los Amigos National Rehabilitation Center, Department of Health Services, County of Los Angeles, Downey, CA,Rancho Research Institute, Downey, CA,Department of Neurology, Keck Medicine of University of Southern California, Los Angeles, CA
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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.
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Whitby J, Nitchingham A, Caplan G, Davis D, Tsui A. Persistent delirium in older hospital patients: an updated systematic review and meta-analysis. DELIRIUM (BIELEFELD, GERMANY) 2022; 1:36822. [PMID: 36936539 PMCID: PMC7614331 DOI: 10.56392/001c.36822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Introduction Delirium is associated with future dementia progression. Yet whether this occurs subclinically over months and years, or persistent delirium merges into worsened dementia is not understood. Our objective was to estimate the prevalence of persistent delirium and understand variation in its duration. Methods We adopted an identical search strategy to a previous systematic review, only including studies using a recognised diagnostic framework for ascertaining delirium at follow-up (persistent delirium). Studies included hospitalised older patients outside critical and palliative care settings. We searched MEDLINE, EMBASE, PsycINFO and the Cochrane Database of Systematic Reviews on 11th January 2022. We applied risk of bias assessments based on Standards of Reporting of Neurological Disorders criteria and assessed strength of recommendations using the grading of recommendation, assessment, development and evaluation (GRADE) approach. Estimates were pooled across studies using random-effects meta-analysis, and we estimated associations with follow-up duration using robust error meta-regression. Results We identified 13 new cohorts, which we added to 10 from the previous systematic review (23 relevant studies, with 39 reports of persistent delirium at 7 time-points in 3186 individuals admitted to hospital care (mean age 82 years and 41% dementia prevalence). Studies were mainly at moderate risk of bias. Pooled delirium prevalence estimates at discharge were 36% (95% CI 22% to 51%, 13 studies). Robust error meta-regression did not show variation in prevalence of persistent delirium over time (-1.6% per month, 95% CI -4.8 to 1.6, p=0.08). Margins estimates for this model indicate a prevalence of persistent delirium of 16% (95% CI 6% to 25%) at 12 months. Conclusions This systematic review emphasises the importance of delirium as a persistent and extensive problem (GRADE certainty = moderate), raising questions on chronic delirium as a clinical entity and how it might evolve into dementia. Addressing persistent delirium will require a whole-system, integrated approach to detect, follow-up and implement opportunities for recovery across all healthcare settings.
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Affiliation(s)
- Jonathan Whitby
- MRC Unit for Lifelong Health and Ageing, University College London
| | | | - Gideon Caplan
- The Prince of Wales Clinical School, University of New South Wales
| | - Daniel Davis
- MRC Unit for Lifelong Health and Ageing, University College London
| | - Alex Tsui
- MRC Unit for Lifelong Health and Ageing, University College London
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11
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Delirium screening tools in the post-anaesthetic care unit: a systematic review and meta-analysis. Aging Clin Exp Res 2022; 34:1225-1235. [PMID: 34981431 DOI: 10.1007/s40520-021-02057-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 12/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Delirium is a serious neurocognitive disorder among surgical patients in the post-anaesthetic care unit (PACU). Despite the development of screening tools to identify delirium, it is not clear which tool is the most accurate and reliable in assessing delirium in the PACU. AIM To examine the diagnostic accuracy of delirium screening tools used in the PACU. METHODS A systematic literature search of CINAHL, MEDLINE, Embase, PsycINFO and Scopus was conducted, using MeSH terms and relevant keywords, from databases establishment to 23 April 2021. Studies were assessed for methodological quality using the Standards for Reporting of Diagnostic Accuracy Studies (STARD) tool. RESULTS A total of 1503 studies were screened from the database search, four studies met the inclusion criteria for this review. Six delirium screening tools used in the PACU were identified in the selected studies. Three studies evaluated screening tools in adult surgical patients without cognitive impairment and dementia. Two studies evaluated screening tools among patients who were scheduled for elective surgery. Review results indicated that two tools, the 4A's test (4AT; sensitivity 96%; specificity 99%) and the 3 min diagnostic interview for the Confusion Assessment Method (3D-CAM; sensitivity 100%; specificity 88%), had greatest validity and reliability as a screening tool for detecting delirium in the PACU. CONCLUSION Results indicate the 4AT and the 3D-CAM are most accurate screening tools to detect delirium in the PACU. Further research is required to validate those tools among a broader surgical population, including patients with cognitive impairment, dementia and those undergoing emergency surgical procedures.
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12
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Ahmed N, Kuo YH. Delirium risk in geriatric hip hemi-arthroplasty (DRIGHA): Development and validation of a novel score using a national data. Injury 2022; 53:1469-1476. [PMID: 35144810 DOI: 10.1016/j.injury.2022.01.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 01/23/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND In-hospital delirium after hip hemi-arthroplasty results in a prolonged hospital course and an increase in morbidity and mortality. Early identification of high-risk patients and preventive strategies can reduce the occurrence of delirium. The purpose of the study is to identify the risk factors of delirium and create a scoring system for point of care physicians. The risk factors were created and validated in the study. HYPOTHESIS Certain factors are associated with in-hospital delirium after hip hemi-arthroplasty in geriatric patients. METHODS The National Surgical Quality Improvement Program (NSQIP) database from 2016 to 2019 was accessed for the study. The study included all geriatric patients, ages 65 years and older, who underwent hip hemi-arthroplasty following a hip fracture. A multivariable analysis was performed to identify the risk of delirium using all the available information including patient demography, timing of surgery, comorbidities, and infective complications. Eighty percent of the data were used to develop a risk model, and 20% of the data were used to validate the model. A Receiving Operating Characteristics (ROC) curve was created. The Area Under the Curve (AUC) was calculated with a 95% confidence interval (CI). A Delirium Risk in Geriatric Hip Hemi-Arthroplasty (DRIGHA) score was created. RESULTS Out of 13,174 patients who qualified for the study, 3924 (29.8%) patients developed in-hospital delirium. The risk model showed advanced age, male gender, prior history of delirium and dementia, certain comorbidities, and complications were associated with a higher incidence of in-hospital delirium. The AUC was 0.79 (95% CI, 0.78-0.80). The DRIGHA score predicted the risk of delirium from 8 to 99.4%. CONCLUSION Certain demography characteristics, comorbidities and infective complications were associated with a higher risk of developing in-hospital delirium. A DRIGHA score can be calculated at the bedside through a web-based calculator. Preventive strategies in high-risk patients will reduce the incidence of delirium.
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Affiliation(s)
- Nasim Ahmed
- Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center, Neptune, NJ, United States; Hackensack Meridian School of Medicine, Nutley, NJ, United States.
| | - Yen-Hong Kuo
- Office of Research Administration, Jersey Shore University Medical Center, Neptune, NJ, United States
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13
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What do hip fracture patients die from? EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2022; 33:751-757. [PMID: 35377075 DOI: 10.1007/s00590-022-03250-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 03/09/2022] [Indexed: 12/25/2022]
Abstract
Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.
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14
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Albanese AM, Ramazani N, Greene N, Bruse L. Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment. Geriatr Orthop Surg Rehabil 2022; 13:21514593211058947. [PMID: 35282299 PMCID: PMC8915233 DOI: 10.1177/21514593211058947] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Introduction Postoperative delirium (POD) is a serious complication occurring in 4–53.3%
of geriatric patients undergoing surgeries for hip fracture. Incidence of
hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in
2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected
to increase, POD is also anticipated to increase. Signficance Postoperative delirium remains the most common complication of emergency hip
fracture surgery leading to high morbidity and mortality rates despite
significant research conducted regarding this topic. This study reviews
literature from 1990 to 2021 regarding POD in geriatric hip fracture
management. Results Potentially modifiable and non-modifiable risk factors for developing POD
include, but are not limited to, male gender, older age, multiple
comorbidities, specific comorbidities (dementia, cognitive impairment,
diabetes, vision impairment, and abnormal blood pressure), low BMI,
preoperative malnutrition, low albumin, low hematocrit, blunted preoperative
cytokines, emergency surgery, time to admission and surgery, preoperative
medical treatment, polypharmacy, delirium-inducing medications, fever,
anesthesia time, and sedation depth and type. Although the pathophysiology
remains unclear, the leading theories suggest neurotransmitter imbalance,
inflammation, and electrolyte or metabolic derangements as the underlying
cause of POD. POD is associated with increased length of hospital stay,
cost, morbidity, and mortality. Prevention and early recognition are key
factors in managing POD. Methods to reduce POD include utilizing
interdisciplinary teams, educational programs for healthcare professionals,
reducing narcotic use, avoiding delirium-inducing medications, and
multimodal pain control. Conclusion While POD is a known complication after hip fracture surgery, further
exploration in prevention is needed. Early identification of risk factors is
imperative to prevent POD in geriatric patients. Early prevention will
enhance delivery of health care both pre- and post-operatively leading to
the best possible surgical outcome and better quality of life after hip
fracture treatment.
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Affiliation(s)
- Anita M Albanese
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Noyan Ramazani
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Natasha Greene
- University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
| | - Laura Bruse
- Adjunct Clinical Assistant Professor Community Faculty, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, USA
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15
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Thirukumaran CP, Ricciardi BF, Cai X, Holloway RG, Li Y, Glance LG. Association of Medicare Mandatory Bundled Payment Reform With Joint Replacement Surgery Use for Beneficiaries With Alzheimer Disease and Related Dementias. JAMA HEALTH FORUM 2022; 3:e215111. [PMID: 35977279 PMCID: PMC8903111 DOI: 10.1001/jamahealthforum.2021.5111] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/15/2021] [Indexed: 11/18/2022] Open
Abstract
Question Is the Comprehensive Care for Joint Replacement (CJR) model associated with changes in hip and knee replacement use for Medicare beneficiaries with Alzheimer disease and related dementias (ADRD)? Findings In this cohort study of 24 598 729 beneficiary-year observations among 9 624 461 unique beneficiaries, CJR was statistically significantly associated with a decrease in hip replacement use for beneficiaries with and without ADRD; however, the gap in use between these groups did not change with CJR implementation. The CJR model was not associated with changes in knee replacement use. Meaning This study found that the CJR model was not associated with a disproportionate reduction in joint replacement use for Medicare beneficiaries with ADRD. Importance Medicare beneficiaries with Alzheimer disease and related dementias (ADRD) are a particularly vulnerable group in whom arthritis is a frequently occurring comorbidity. Medicare’s mandatory bundled payment reform—the Comprehensive Care for Joint Replacement (CJR) model—was intended to improve quality and reduce spending in beneficiaries undergoing joint replacement surgical procedures for arthritis. In the absence of adjustment for clinical risk, hospitals may avoid performing elective joint replacements for beneficiaries with ADRD. Objective To evaluate the association of the CJR model with utilization of joint replacements for Medicare beneficiaries with ADRD. Design, Setting, and Participants This cohort study used national Medicare data from 2013 to 2017 and multivariable linear probability models and a triple differences estimation approach. Medicare beneficiaries with a diagnosis of arthritis were identified from 67 metropolitan statistical areas (MSAs) mandated to participate in CJR and 104 control MSAs. Data were analyzed from July 2020 to July 2021. Exposures Implementation of the CJR model in 2016. Main Outcomes and Measures Outcomes were separate binary indicators for whether or not a beneficiary underwent hip or knee replacement. Key independent variables were the MSA group, before-CJR and after-CJR phase, ADRD diagnosis, and their interactions. The linear probability models controlled for beneficiary characteristics, MSA fixed effects, and time trends. Results The study included 24 598 729 beneficiary-year observations for 9 624 461 unique beneficiaries, of which 250 168 beneficiaries underwent hip and 474 751 underwent knee replacements. The mean (SD) age of the 2013 cohort was 77.1 (7.9) years, 3 110 922 (66.4%) were women, 3 928 432 (83.8%) were non-Hispanic White, 792 707 (16.9%) were dually eligible for Medicaid, and 885 432 (18.9%) had an ADRD diagnosis. Before CJR implementation, joint replacement rates were lower among beneficiaries with ADRD (hip replacements: 0.38% vs 1.17% for beneficiaries with and without ADRD, respectively; P < .001; knee replacements: 0.70% vs 2.25%; P < .001). After controlling for relevant covariates, CJR was associated with a 0.07-percentage-point decline in hip replacements for beneficiaries with ADRD (95% CI, −0.13 to −0.001; P = .046) and a 0.07-percentage-point decline for beneficiaries without ADRD (95% CI, −0.12 to −0.02; P = .01) residing in CJR MSAs compared with beneficiaries in control MSAs. However, this change in hip replacement rates for beneficiaries with ADRD was not statistically significantly different from the change for beneficiaries without ADRD (percentage point difference: 0.01; 95% CI, −0.08 to 0.09; P = .88). No statistically significant changes in knee replacement rates were noted for beneficiaries with ADRD compared with those without ADRD with CJR implementation (percentage point difference: −0.03, 95% CI, −0.09 to 0.02; P = .27). Conclusions and Relevance In this cohort study of Medicare beneficiaries with arthritis, the CJR model was not associated with a decline in joint replacement utilization among beneficiaries with ADRD compared with beneficiaries without ADRD in the first 2 years of the program, thereby alleviating patient selection concerns.
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Affiliation(s)
- Caroline P. Thirukumaran
- Department of Orthopaedics, University of Rochester, New York
- Department of Public Health Sciences, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Benjamin F. Ricciardi
- Department of Orthopaedics, University of Rochester, New York
- Center for Musculoskeletal Research, University of Rochester, New York
| | - Xueya Cai
- Department of Biostatistics and Computational Biology, University of Rochester, New York
| | - Robert G. Holloway
- Department of Neurology, University of Rochester, New York
- Department of Medicine, University of Rochester, New York
| | - Yue Li
- Department of Public Health Sciences, University of Rochester, New York
| | - Laurent G. Glance
- Department of Public Health Sciences, University of Rochester, New York
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, New York
- RAND Health, RAND, Boston, Massachusetts
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16
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Zhou Q, Zhou X, Zhang Y, Hou M, Tian X, Yang H, He F, Chen X, Liu T. Predictors of postoperative delirium in elderly patients following total hip and knee arthroplasty: a systematic review and meta-analysis. BMC Musculoskelet Disord 2021; 22:945. [PMID: 34772392 PMCID: PMC8588632 DOI: 10.1186/s12891-021-04825-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 10/26/2021] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is widely reported as a common postoperative complication following total joint arthroplasty (TJA) of the hip and knee in elderly patients, leading to many adverse effects. We sought to investigate predictors of delirium after TJA. METHODS PubMed, EMBASE, Cochrane Library and Web of Science were searched up to 2020 for studies examining POD following TJA in elderly patients. Pooled odds ratio (OR) and mean difference (MD) of those who experienced delirium compared to those who did not were calculated for each variable. The Newcastle-Ottawa Scale (NOS) was used for the study quality evaluation. RESULTS Fifteen studies with 31 potential factors were included. In the primary analysis, 9 factors were associated with POD, comprising advanced age (MD 3.81; 95% confidence interval (CI) 1.80-5.83), dementia (OR 24.85; 95% CI 7.26-85.02), hypertension (OR 2.26; 95% CI 1.31-3.89), diabetes (OR 2.02; 95% CI 1.15-3.55), stroke (OR 14.61; 95% CI 5.26-40.55), psychiatric illness (OR 2.72; 95% CI 1.45-5.08), use of sedative-hypnotics (OR 6.42; 95% CI 2.53-16.27), lower preoperative levels of hemoglobin (MD - 0.56; 95% CI - 0.89-- 0.22), and lower preoperative mini-mental state examination score (MD - 0.40; 95% CI - 0.69-- 0.12). Twelve studies were included in the systematic review, of which 24 factors were additionally correlated with POD using single studies. CONCLUSIONS Strategies and interventions should be implemented for the elderly patients receiving TJA surgeries with potential predictors identified in this meta-analysis.
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Affiliation(s)
- Quan Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Xinfeng Zhou
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Yijian Zhang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Mingzhuang Hou
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Xin Tian
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Huilin Yang
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.,Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Fan He
- Orthopaedic Institute, Medical College, Soochow University, Suzhou, 215007, China
| | - Xi Chen
- Department of Pathology, The Third Affiliated Hospital of Soochow University, No.185 Juqian Road, Changzhou, 213003, Jiangsu, China.
| | - Tao Liu
- Department of Orthopaedics, The First Affiliated Hospital of Soochow University, No. 899 Pinghai Road, Suzhou, 215006, Jiangsu, China.
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17
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The Risk of Preoperative Central Nervous System-Acting Medications on Delirium Following Hip or Knee Surgery: A Matched Case-Control Study. Drug Saf 2021; 45:75-82. [PMID: 34748199 DOI: 10.1007/s40264-021-01136-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Medicines acting on the central nervous system can increase the risk of postoperative delirium, but the specific medicines associated with greatest risk remain unclear. OBJECTIVES We aimed to examine the risk of individual central nervous system-acting medicines used preoperatively on delirium after hip or knee surgery. METHODS A matched case-control study was conducted using data from the Australian Government Department of Veterans' Affairs. We included people aged 65 years or older who had knee or hip surgery between 2000 and 2019. People with hip or knee surgery who developed postoperative delirium were cases and controls were people with hip or knee surgery but who did not develop postoperative delirium. Use of medicines including anxiolytics, sedatives, and hypnotics, opioid analgesics and antidepressants prior to surgery was compared between cases and controls. RESULTS A total of 2614 patient cases with postoperative delirium were matched by same sex, age (±2 years), and year of admission (±2 years) with 7842 controls without postoperative delirium. Cases were more likely to be exposed to nitrazepam (odds ratio [OR] = 1.81, 95% confidence interval [CI] 1.24-2.64), sertraline (OR = 1.50, 95% CI 1.20-1.87), mirtazapine (OR = 1.38, 95% CI 1.11-1.74), venlafaxine (OR = 1.42, 95% CI 1.02-1.98), citalopram (OR = 1.54, 95% CI 1.19-1.99), escitalopram (OR = 1.42, 95% CI 1.06-1.89) or fluvoxamine (OR = 5.01, 95% CI 2.15-11.68) prior to surgery than controls. At the class level, exposure to benzodiazepines (OR = 1.20, 95% CI 1.05-1.37) and antidepressants (OR = 1.64, 95% CI 1.47-1.83) prior to surgery was significantly higher in cases than in controls. The numbers needed to treat to harm for one additional delirium case were 43 for sertraline, 40 for citalopram, 57 for mirtazapine and 26 for nitrazepam. Whereas, the numbers needed to treat to harm were found to be 20 for sertraline, 17 for citalopram, 19 for mirtazapine and 10 for nitrazepam in the 85 years or older age group, indicating that the harmful effect of these medicines is pronounced as age advances. CONCLUSIONS People who developed delirium following hip or knee surgery were more likely to be exposed to nitrazepam, sertraline, mirtazapine, venlafaxine, citalopram, escitalopram or fluvoxamine at the time of admission for surgery. Planning to reduce use of these medicines well prior to surgery may decrease the risk of postoperative delirium.
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18
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Han QYC, Rodrigues NG, Klainin-Yobas P, Haugan G, Wu X. Prevalence, Risk Factors, and Impact of Delirium on Hospitalized Older Adults With Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc 2021; 23:23-32.e27. [PMID: 34648761 DOI: 10.1016/j.jamda.2021.09.008] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 08/03/2021] [Accepted: 09/04/2021] [Indexed: 12/29/2022]
Abstract
OBJECTIVES High prevalence of delirium superimposed on dementia (DSD) was previously reported, with associated negative impact on hospitalized older adults. However, data were conflicting, and no meta-analysis has been conducted. Although dementia is the leading risk factor for delirium, risk factors for DSD have not been adequately studied. This systematic review and meta-analysis aims to elucidate the prevalence, risk factors, and impact of DSD in hospitalized older adults. Comparisons were made between older adults with DSD and persons with dementia alone (PWDs). DESIGN Systematic review and meta-analysis. SETTING AND PARTICIPANTS Observational studies reporting prevalence, risk factors, or impact of DSD in hospitalized older adults. METHODS Database search was conducted till December 2020 in PubMed, Embase, CENTRAL, PsycINFO, CINAHL, Scopus, Web of Science, ProQuest, and OpenGrey for relevant primary and secondary studies. A piloted data collection form was used for data extraction, and methodological quality was assessed using Joanna Briggs Institute critical appraisal checklists. Meta-analyses, with risk ratio and mean differences as effect measures, were performed using random effects model with Review Manager software. Cochran's Q and I2 statistics were used to assess heterogeneity, which was investigated using subgroup analyses. RESULTS A total of 81 studies were eligible. The pooled prevalence of DSD was 48.9%, with the highest prevalence found in the Americas and orthopedic wards. Risk factors, including nonmodifiable hospital-, illness-, and medication-related factors, were found to precipitate DSD. Patients with DSD had longer length of hospitalization, disclosed worse cognitive and functional outcomes, and a higher risk of institutionalization and mortality than patients with dementia. CONCLUSIONS AND IMPLICATIONS These findings suggested high prevalence and detrimental impact of DSD in hospitalized older adults, highlighting a need for early identification, prevention, and treatments. Further research on risk factors of DSD should be conducted as data were sparse and conflicting. Future high-quality studies regarding DSD are warranted to improve knowledge of this common but under-recognized phenomenon.
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Affiliation(s)
- Qin Yun Claudia Han
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Natalie Grace Rodrigues
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Piyanee Klainin-Yobas
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Gørill Haugan
- Department of Public Health and Nursing, Centre for Health Promoting Research, Norwegian University of Science and Technology, Trondheim, Trøndelag, Norway
| | - XiVivien Wu
- Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
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19
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Abate SM, Checkole YA, Mantedafro B, Basu B, Aynalem AE. Global prevalence and predictors of postoperative delirium among non-cardiac surgical patients: A systematic review and meta-analysis. INTERNATIONAL JOURNAL OF SURGERY OPEN 2021. [DOI: 10.1016/j.ijso.2021.100334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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20
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Goto H, Yamauchi T, Okumura K, Matsuoka K, Toritsuka M, Yasuno F, Uemura H, Kuki K, Makinodan M, Kishimoto T. A retrospective study of factors associated with persistent delirium. Psychogeriatrics 2021; 21:193-200. [PMID: 33429465 DOI: 10.1111/psyg.12655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/26/2020] [Accepted: 12/24/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND It has been reported that delirium causes various problems. Many researchers have reported the risk factors associated with the onset of delirium; however, there are few reports focused on persistent delirium. This study aimed to identify the risk factors associated with persistent delirium. METHODS A total of 573 patients hospitalised in Nara Prefecture General Medical Centre from October 2014 through September 2017 who were referred to the psychiatry consultation service were included in this study. Persistent delirium was defined as delirium lasting for 14 days or more. A retrospective study was carried out based on the patients' records. The relationship between various background factors and persistent delirium was statistically analysed. RESULTS Of the 573 hospitalised patients, 295 were diagnosed as having delirium. Forty-six patients with persistent delirium and 181 patients with nonpersistent delirium were included in this study. Multivariable logistic regression analyses revealed that male gender, opioid analgesics use, non-opioid analgesics use, and low serum sodium were significantly and independently associated with persistent delirium. Ramelteon or trazodone was used significantly more in persistent delirium, although each use was not significant. CONCLUSION This is the first study to reveal that male gender and use of analgesics were associated with persistent delirium in general hospital. However, as this is a case-control study and may contain bias, future cohort studies and intervention studies are needed. It is also necessary to investigate the relevance of the 'degree of pain' behind the use of analgesics.
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Affiliation(s)
- Harue Goto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan.,Department of Psychiatry, Nara Prefecture General Medical Centre, Nara, Japan
| | - Takahira Yamauchi
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan.,Department of Psychiatry, Nara Prefecture General Medical Centre, Nara, Japan
| | - Kazuki Okumura
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Kiwamu Matsuoka
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Michihiro Toritsuka
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Fumihiko Yasuno
- Department of Psychiatry, National Centre for Geriatrics and Gerontology, Obu, Japan
| | - Hideki Uemura
- Department of Psychiatry, Nara Prefecture General Medical Centre, Nara, Japan
| | - Kazutaka Kuki
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Manabu Makinodan
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Toshifumi Kishimoto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
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Takahashi N, Hiraki A, Kawahara K, Nagata M, Yoshida R, Matsuoka Y, Tanaka T, Obayashi Y, Sakata J, Nakashima H, Arita H, Shinohara M, Nakayama H. Postoperative delirium in patients undergoing tumor resection with reconstructive surgery for oral cancer. Mol Clin Oncol 2021; 14:60. [PMID: 33604050 DOI: 10.3892/mco.2021.2222] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 09/25/2020] [Indexed: 12/19/2022] Open
Abstract
Many attempts have been made to identify the risk factors for postoperative delirium, but this has proved difficult due to its complex morbidity. Furthermore, there is little information on postoperative delirium in patients undergoing tumor resection and reconstructive surgery for oral cancer. The aim of the current study was to investigate the incidence of and risk factors for postoperative delirium in patients undergoing resection and reconstructive surgery for oral cancer. The present study included 104 patients with pedicle or free flap reconstruction. Postoperative delirium developed in 22 (21.2%) of these patients. The mean time to onset of postoperative delirium was 2.5±1.0 days and the duration of delirium was 1.9±1.2 days. Univariate analysis demonstrated that the occurrence of postoperative delirium was significantly correlated with operating time (P=0.033), duration of anesthesia (P=0.039), amount of blood loss (P=0.027), method of reconstruction (P=0.008), type of flap used (P=0.009) and time until postoperative ambulation (P=0.0008). Low postoperative red blood cell count (P=0.004), hemoglobin (P=0.004) and hematocrit (P=0.004) were significantly associated with delirium, but preoperative blood test results were not. The multiple logistic regression analysis of these risk factors revealed that the only significant correlation that remained was between postoperative delirium and the time to ambulation after surgery (P=0.005). Since 2009, the Department of Oral and Maxillofacial Surgery, Kumamoto University Hospital has promoted ambulation after the first two postoperative days for patients with oral cancer undergoing tumor resection with reconstruction, and the occurrence of postoperative delirium has decreased from 29.2 to 14.0%. The results of the current study suggest that early postoperative ambulation in patients who undergo reconstructive surgery for oral cancer is effective for preventing postoperative delirium.
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Affiliation(s)
- Nozomu Takahashi
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Akimitsu Hiraki
- Section of Oral Oncology, Department of Oral and Maxillofacial Surgery, Fukuoka Dental College, Fukuoka 814-0193, Japan
| | - Kenta Kawahara
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Masashi Nagata
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Ryoji Yoshida
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Yuichiro Matsuoka
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Takuya Tanaka
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Yuko Obayashi
- Section of Oral Oncology, Department of Oral and Maxillofacial Surgery, Fukuoka Dental College, Fukuoka 814-0193, Japan
| | - Junki Sakata
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Hikaru Nakashima
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | - Hidetaka Arita
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
| | | | - Hideki Nakayama
- Department of Oral and Maxillofacial Surgery, Faculty of Life Sciences, Kumamoto University, Kumamoto 860-8556, Japan
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de Sire A, Zeppegno P, Forni F, Sgreccia’ M, Gagliardi’ VP, Pogliacomi F, Sabbatini M. Delirium risk factors analysis post proximal femur fracture surgery in elderly. ACTA BIO-MEDICA : ATENEI PARMENSIS 2021; 92:e2021569. [PMID: 35604255 PMCID: PMC9437687 DOI: 10.23750/abm.v92is3.12571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIM The increase in the average-age and in the percentage of elderly people implies an exponential increase in fractures of the proximal femur. A common consequence of hip fracture in elderly patients is delirium, characterized by cognitive confusion or a lethargic-type condition. Predisposing factors have been identified, but risk factors assessment useful for managing clinical intervention, has not received unanimous consent. This work aims to identify the potential risk factors for delirium in the elderly operated for hip fracture. METHODS In this prospective observational study, we included 83 patients aged ≥65 years. Patients undergoing osteosynthesis of the femur and hip replacement for fractures were included. Patients already delusional in the pre-operative period were excluded. At the time, deadlines T0 (pre-operative), and T1,T3,T7 post-operative day, delirium, hematic parameters, blood transfusions, were assessed. RESULTS Level of delirium was assessed obtaining 80% not delusional and 20% delusional. Glycemia and hemoglobin were not found to be risk factors, although they are known to influence cognitive status; we hypothesize they should be considered predisposing factors. Comorbidities such as atrial fibrillation and Chronic Obstructive Pulmonary Disease were found associated with delirium. The most advanced age, anxiolytic drugs, the use of benzodiazepine as anaesthetic, the time surgical waiting, were found significantly associated with delirium. CONCLUSIONS Taken together, findings of this prospective observational study showed that environmental and metabolic risk factors might contribute to make elderly susceptible to develop postoperative delirium following hip surgery. Thus, these patients should be adequately assessed and monitored. (www.actabiomedica.it).
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Affiliation(s)
- Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, Catanzaro, Italy
| | - Patrizia Zeppegno
- Department of Translational Medicine, Institute of Psychiatry, University of East Piedmont, Novara, Italy;,Psychiatry Unit “Maggiore della Carita” Hospital, Novara, Italy
| | - Francesca Forni
- Department of Orthopaedics and Traumatology, “Maggiore della Carita” Hospital, Novara, Italy;,Specialization School in Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | - Massimo Sgreccia’
- Department of Orthopaedics and Traumatology, “Maggiore della Carita” Hospital, Novara, Italy;,Specialization School in Orthopedics and Traumatology, University of Pavia, Pavia, Italy
| | | | - Francesco Pogliacomi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Maurizio Sabbatini
- Department of Science and Technology Innovation, University of East Piedmont, Alessandria, Italy
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Wu J, Yin Y, Jin M, Li B. The risk factors for postoperative delirium in adult patients after hip fracture surgery: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2021; 36:3-14. [PMID: 32833302 DOI: 10.1002/gps.5408] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 05/30/2020] [Accepted: 08/08/2020] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Postoperative delirium (POD) is the most common complication in patients after hip fracture surgery, and the incidence of POD is associated with mortality and disability in patients following hip fracture surgery. Therefore, this study aimed to identify the individual as well as anesthetic and operative risk factors associated with the POD in adult patients after hip fracture surgery. METHODS We searched relevant articles published to February 2020 in Cochrane Library, PubMed, and Embase. Studies involving adult patients who underwent hip fracture surgery were regarded as relevant if the studies contained the individual or anesthetic and surgical characteristics of participants. The pooled relative risk ratios (RRs) or weight mean difference of the variables were estimated by the Mantel-Haenszel or Inverse-Variance methods. RESULTS A total of 44 studies were included, which altogether included 104572 participants with hip fracture surgery (17703 patients with POD and 86869 patients without POD) and the incidence of POD was 16.93%. A total of 14 risk factors, classified into two categories which were individual as well as anesthetic and operative factors, were identified originally, which included age (weight mean difference [WMD]:2.33;95% confidential interval [CI]: 1.64-3.03), sex (RR: 0.89; 95% CI:0.85-0.93), American society of Anesthesiologists classification(RR:0.56; 95%CI:0.51-0.59), body mass index (WMD:-0.62; 95%CI:-0.81 to -0.44), function dependency(RR:1.52; 95% CI:1.24-1.87), visual impairment (RR:1.62; 95% CI: 1.16-2.27), smoking (RR:0.86; 95% CI:0.79-0.94), preoperative delirium (RR: 2.71; 95% CI: 2.50-2.72), dementia (RR:2.60; 95% CI:2.50-2.72), hypertension (RR: 1.10; 95% CI:1.04-1.15), chronic obstructive pulmonary disease (RR:1.08; 95% CI: 1.01-1.16), regional anesthesia (RR:1.20; 95% CI: 1.01-1.43), transfusion (RR: 1.41; 95% CI: 1.22-1.63), and elective surgery (RR: 0.91; 95% CI: 0.84-0.99). CONCLUSIONS Patients possessed above risk factors might be high-risk patients. Clinician should maintain keen vigilance at those patients.
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Affiliation(s)
- Juan Wu
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
| | - Yushuang Yin
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
| | - Man Jin
- Department of Anesthesiology, Xinqiao Hospital, Army Medical University, Chongqing, China
| | - Bixi Li
- Department of Anesthesiology, Central Theater Command General Hospital of the Chinese People's Liberation Army, Wuhan, China
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Blandfort S, Gregersen M, Rahbek K, Juul S, Damsgaard EM. The short IQCODE as a predictor for delirium in hospitalized geriatric patients. Aging Clin Exp Res 2020; 32:1969-1976. [PMID: 31722092 DOI: 10.1007/s40520-019-01412-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 11/02/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Delirium is a serious complication, which occurs frequently in older patients with pre-existing cognitive impairment. There is a need for a simple tool to assess chronic cognitive impairment and the associated risk of delirium during hospitalization. AIMS To assess the usefulness of the short IQCODE questionnaire in predicting delirium during hospitalization in older patients in a geriatric ward. METHODS A prognostic study in the Geriatric Department at Aarhus University Hospital, Aarhus Denmark. Consecutive patients were enrolled during March to December, 2017. After consent of the patient, the staff interviewed the relatives by phone using the short IQCODE questionnaire. Delirium was assessed morning and evening until discharge by the Confusion Assessment Method. The ability of short IQCODE to predict delirium was examined. RESULTS Three hundred and fifty-three patients were eligible, and 306 completed the IQCODE. Delirium occurred among 19% of the patients during hospitalization. The IQCODE score was associated with the risk of delirium with a receiver operating characteristic (ROC) area of 0.72. A cut-point of 3.3 could separate the patients in a larger group with a risk of approximately 26% to develop delirium and a smaller group having a risk of approximately 6%. CONCLUSION The IQCODE is a useful tool to predict delirium among older inpatients, but it may not stand alone. It can be a useful supplement to other clinical information and observations in detecting patients needing dementia-friendly treatment and care.
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Affiliation(s)
- S Blandfort
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - M Gregersen
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - K Rahbek
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - S Juul
- Department of Public Health, Aarhus University, Aarhus, Denmark
| | - E M Damsgaard
- Department of Geriatrics, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
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Aldwikat RK, Manias E, Nicholson P. Incidence and risk factors for acute delirium in older patients with a hip fracture: A retrospective cohort study. Nurs Health Sci 2020; 22:958-966. [PMID: 32623791 DOI: 10.1111/nhs.12753] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 06/29/2020] [Accepted: 06/30/2020] [Indexed: 12/20/2022]
Abstract
This retrospective cohort study aimed to determine the incidence, and preoperative, intraoperative, and postoperative risk factors for postoperative delirium in older patients undergoing surgical fixation of a hip fracture. Electronic medical records were examined of 260 patients who underwent a surgical fixation of a hip fracture between June 2017 and October 2018 at a university-affiliated tertiary care hospital in Victoria, Australia. Demographic, clinical, and perioperative data were examined for potential risk factors for postoperative delirium. Of the 260 patients, 63 patients (24.2%) developed delirium postoperatively. Univariate logistic regression analysis indicated that advanced age, comorbidity, cognitive impairment, dementia, American Society of Anesthesiologists score, and antipsychotic usage were significant risk factors for delirium, while doses of paracetamol, fentanyl, and diazepam showed complex associations. Multivariate logistic regression analysis determined comorbidity and cognitive impairment as independent risk factors for the development of delirium. This study demonstrates the importance of evaluation of medications prescribed in the perioperative period as modifiable risk factors, in order to identify patients at high risk of delirium and enable targeted monitoring and treatment during patients' hospitalization.
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Affiliation(s)
- Rami K Aldwikat
- School of Nursing and Midwifery, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Elizabeth Manias
- School of Nursing and Midwifery, Centre for Quality and Patients Safety Research, Faculty of Health, Geelong, Victoria, Australia
| | - Patricia Nicholson
- School of Nursing and Midwifery, Centre for Quality and Patients Safety Research, Faculty of Health, Deakin University Geelong, Geelong, Victoria, Australia
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Bai J, Liang Y, Zhang P, Liang X, He J, Wang J, Wang Y. Association between postoperative delirium and mortality in elderly patients undergoing hip fractures surgery: a meta-analysis. Osteoporos Int 2020; 31:317-326. [PMID: 31741024 DOI: 10.1007/s00198-019-05172-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 09/18/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Postoperative delirium (POD) is a common complication in elderly surgical patients. Patients undergoing hip fractures surgery who are often characterized by advanced age could be particularly prone to suffering POD. We performed a meta-analysis to assess the association between POD and mortality in elderly patients undergoing hip fractures surgery. This meta-analysis included twenty-one cohort studies, and the pooled outcomes demonstrated that approximated one-fourth of patients undergoing hipfracture surgery would develop POD, and delirium increased the mortality in these patients. METHODS We searched PubMed, Embase, Web of Science, and Scopus for studies that investigated the effect of POD on mortality in elderly patients undergoing hip fracture surgery. Two reviewers independently selected studies, assessed quality, and extracted data. Statistical analyses were performed by STATA 14.0 and RevMan 5.3. Risk ratios (RRs) with 95% confidence intervals (CIs) were derived using random or fixed-effects model. RESULTS Twenty-one cohort studies enrolling a total of 6288 patients were included, and the pooled prevalence (95% CI) of POD was 28% (23-34%). POD was associated with an increase in perioperative mortality (30-day or in-hospital mortality) [12 studies, 3123 patients, relative risk (RR) (95% CI) 2.79 (1.97-3.93)], 6-month mortality [6 studies, 1673 patients, 2.51 (1.99-3.16)], 1-year mortality [6 studies, 1896 patients, 1.98 (1.62-2.41)], and more than 1-year mortality [8 studies, 1926 patients, 2.06 (1.60-2.64)]. CONCLUSIONS Our meta-analysis demonstrated that approximated one-fourth of patients undergoing hip fracture surgery would develop POD, and delirium increased the short-term and long-term mortality in these patients.
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Affiliation(s)
- J Bai
- Department of Orthopedics, The Second Affiliated Hospital of Bengbu Medical College, Bengbu, 233000, China
| | - Y Liang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Nantong West Road 98, Yangzhou, 225001, China
| | - P Zhang
- Department of Orthopedics, The Second XiangYa Hospital, Central South University, Changsha, 410011, China
| | - X Liang
- Educational Administration Section, The Second Hospital of Dalian Medical University, Dalian, 116027, China
| | - J He
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Nantong West Road 98, Yangzhou, 225001, China
| | - J Wang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Nantong West Road 98, Yangzhou, 225001, China.
| | - Y Wang
- Department of Orthopedics, Northern Jiangsu People's Hospital, Clinical Medical College of Yangzhou University, Nantong West Road 98, Yangzhou, 225001, China.
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Zhong H, Wang Y, Wang Y, Wang B. Comparison of the effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty. Exp Ther Med 2019; 17:4421-4426. [PMID: 31086576 PMCID: PMC6489064 DOI: 10.3892/etm.2019.7465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/18/2019] [Indexed: 12/19/2022] Open
Abstract
Effect and clinical value in general anesthesia and combined spinal-epidural anesthesia in elderly patients undergoing hip arthroplasty were compared. One hundred and six patients with hip arthroplasty in the Affiliated Nanhua Hospital, University of South China from May 2013 to July 2015 were selected as the research subjects, including 50 patients in the study group who received combined spinal-epidural anesthesia by ondansetron hydrochloride tablets combined with spinal-epidural puncture kit, and 56 patients in the control group who received general anesthesia by fast-induced endotracheal intubation. Retrospective analysis was performed in terms of anesthesia effect, complete block time, anesthesia onset time, hemodynamic parameters at different time points before and after the surgery, and adverse reactions after the surgery. The study group had a statistically shorter onset time and a statistically shorter complete block time than the control group (P<0.05). No significant difference in the heart rate, systolic blood pressure or diastolic blood pressure before the surgery in the two groups was shown (P>0.05); the heart rate, systolic blood pressure, and diastolic blood pressure in the study group 20 min after the start of the operation and 15 min before the end of the operation were significantly higher those in the control group (P<0.05); the adverse reactions such as venous thrombosis, pulmonary infection, and nausea and vomiting in the study group were fewer than those in the control group (P<0.05). For elderly patients with fracture surgery, both the general anesthesia and the combined spinal-epidural anesthesia can maintain a good anesthesia effect, but the combined spinal-epidural anesthesia can shorten the onset time and has less impact on the patient's hemodynamic parameters and less incidence of complications, thus worthy of clinical promotion.
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Affiliation(s)
- Huanhui Zhong
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Yongdong Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Yiqun Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
| | - Baiyun Wang
- Department of Anesthesiology, Affiliated Nanhua Hospital, University of South China, Hengyang, Hunan 421002, P.R. China
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Blandfort S, Gregersen M, Rahbek K, Juul S, Damsgaard EM. Single-bed rooms in a geriatric ward prevent delirium in older patients. Aging Clin Exp Res 2019; 32:141-147. [DOI: 10.1007/s40520-019-01173-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 03/09/2019] [Indexed: 10/27/2022]
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Surgical delay is a risk factor of delirium in hip fracture patients with mild-moderate cognitive impairment. Aging Clin Exp Res 2019; 31:41-47. [PMID: 29949026 DOI: 10.1007/s40520-018-0985-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/01/2018] [Indexed: 12/30/2022]
Abstract
AIM To investigate the relationship between onset of delirium and time to surgery in hip fracture (HF) patients with a different degree of cognitive impairment. METHODS Retrospective analysis of a prospective database of 939 older adults, aged ≥ 75 years admitted with a fragility HF. Subjects underwent a Comprehensive Geriatric Assessment on admission, evaluating health status, prefracture functional status in basic and instrumental activities of daily living, and walking ability. According to the Short Portable Mental Status Questionnaire score, patients were stratified into three categories: cognitively healthy (0-2 errors), mildly to moderately impaired (3-7 errors) and severely impaired (8-10 errors). Time to surgery (from admission) was expressed as days. The occurrence of delirium was ascertained daily by Confusion Assessment Method. RESULTS Two hundred ninety-two (31.1%) patients experienced delirium during in-hospital stay. They were older, with a higher degree of comorbidity and functional impairment compared to patients without delirium. In multivariate analysis, surgical delay resulted a significant independent risk factor for delirium (HR 1.11, 95% CI 1.01-1.24), along with age, prefracture functional disability and cognitive impairment. When the analysis was performed accounting for the cognitive categories, surgical delay demonstrated to increase the risk of delirium only in the subcategory of mildly to moderately impaired patients, while no significant effect was demonstrated in patients cognitively healthy or severely impaired. CONCLUSIONS The study supports the concept that older adults with HF should undergo surgery quickly. Patients with mild-to-moderate cognitive impairment should be primarily considered as the best target for interventions aiming to reduce time to surgery.
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Öz T, Özhasenekler A, Pamukçu Günaydın G, Otal Y, Kurtoğlu Çelik G, Coşkun S, Tanrıverdi F, Gökhan Ş. Importance of Sodium Levels for Geriatric Patients Presented to the Emergency Department with a Simple Fall. ANKARA MEDICAL JOURNAL 2018. [DOI: 10.17098/amj.497477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Khan BA, Perkins AJ, Campbell NL, Gao S, Khan SH, Wang S, Fuchita M, Weber DJ, Zarzaur BL, Boustani MA, Kesler K. Preventing Postoperative Delirium After Major Noncardiac Thoracic Surgery-A Randomized Clinical Trial. J Am Geriatr Soc 2018; 66:2289-2297. [PMID: 30460981 PMCID: PMC10924437 DOI: 10.1111/jgs.15640] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To assess the efficacy of haloperidol in reducing postoperative delirium in individuals undergoing thoracic surgery. DESIGN Randomized double-blind placebo-controlled trial. SETTING Surgical intensive care unit (ICU) of tertiary care center. PARTICIPANTS Individuals undergoing thoracic surgery (N=135). INTERVENTION Low-dose intravenous haloperidol (0.5 mg three times daily for a total of 11 doses) administered postoperatively. MEASUREMENTS The primary outcome was delirium incidence during hospitalization. Secondary outcomes were time to delirium, delirium duration, delirium severity, and ICU and hospital length of stay. Delirium was assessed using the Confusion Assessment Method for the ICU and delirium severity using the Delirium Rating Scale-Revised. RESULTS Sixty-eight participants were randomized to receive haloperidol and 67 placebo. No significant differences were observed between those receiving haloperidol and those receiving placebo in incident delirium (n=15 (22.1%) vs n=19 (28.4%); p = .43), time to delirium (p = .43), delirium duration (median 1 day, interquartile range (IQR) 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, ICU length of stay (median 2.2 days, IQR 1-3.3 days vs median 2.3 days, IQR 1-4 days; p = .29), or hospital length of stay (median 10 days, IQR 8-11.5 days vs median 10 days, IQR 8-12 days; p = .41). In the esophagectomy subgroup (n = 84), the haloperidol group was less likely to experience incident delirium (n=10 (23.8%) vs n=17 (40.5%); p = .16). There were no differences in time to delirium (p = .14), delirium duration (median 1 day, IQR 1-2 days vs median 1 day, IQR 1-2 days; p = .71), delirium severity, or hospital length of stay (median 11 days, IQR 10-12 days vs median days 11, IQR 10-15 days; p = .26). ICU length of stay was significantly shorter in the haloperidol group (median 2.8 days, IQR 1.1-3.8 days vs median 3.1 days, IQR 2.1-5.1 days; p = .03). Safety events were comparable between the groups. CONCLUSION Low-dose postoperative haloperidol did not reduce delirium in individuals undergoing thoracic surgery but may be efficacious in those undergoing esophagectomy. J Am Geriatr Soc 66:2289-2297, 2018.
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Affiliation(s)
- Babar A. Khan
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
- Department of Medicine, Center for Aging Research, Indiana University, Indianapolis, Indiana
- Department of Medicine, Regenstrief Institute, Inc., Indianapolis, Indiana
- Department of Medicine, Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indiana University, Indianapolis, Indiana
| | - Anthony J. Perkins
- Department of Statistics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Noll L. Campbell
- Department of Medicine, Center for Aging Research, Indiana University, Indianapolis, Indiana
- Department of Medicine, Regenstrief Institute, Inc., Indianapolis, Indiana
- Department of Medicine, Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indiana University, Indianapolis, Indiana
- Eskenazi Health, Indianapolis, Indiana
- Department of Pharmacy Practice, College of Pharmacy, Purdue University, West Lafayette, Indiana
| | - Sujuan Gao
- Department of Statistics, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Sikandar H. Khan
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Sophia Wang
- Department of Psychiatry, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Mikita Fuchita
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Daniel J. Weber
- Department of Surgery, University of California, San Francisco, San Francisco, California
| | - Ben L. Zarzaur
- Department of Surgery, School of Medicine, Indiana University, Indianapolis, Indiana
| | - Malaz A. Boustani
- Department of Medicine, School of Medicine, Indiana University, Indianapolis, Indiana
- Department of Medicine, Center for Aging Research, Indiana University, Indianapolis, Indiana
- Department of Medicine, Regenstrief Institute, Inc., Indianapolis, Indiana
- Department of Medicine, Center for Health Innovation and Implementation Science, Indiana Clinical and Translational Sciences Institute, Indiana University, Indianapolis, Indiana
| | - Kenneth Kesler
- Department of Surgery, School of Medicine, Indiana University, Indianapolis, Indiana
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Hovaguimian F, Tschopp C, Beck-Schimmer B, Puhan M. Intraoperative ketamine administration to prevent delirium or postoperative cognitive dysfunction: A systematic review and meta-analysis. Acta Anaesthesiol Scand 2018; 62:1182-1193. [PMID: 29947091 DOI: 10.1111/aas.13168] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 05/08/2018] [Accepted: 05/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Postoperative cognitive complications are associated with substantial morbidity and mortality. Ketamine has been suggested to have neuroprotective effects in various settings. This systematic review evaluates the effects of intraoperative ketamine administration on postoperative delirium and postoperative cognitive dysfunction (POCD). METHODS Medline, Embase and Central were searched to 4 March 2018 without date or language restrictions. We considered randomised controlled trials (RCTs) comparing intraoperative ketamine administration versus no intervention in adults undergoing surgery under general anaesthesia. Primary outcomes were postoperative delirium and POCD. Non-cognitive adverse events, mortality and length of stay were considered as secondary outcomes. Data were independently extracted. The quality of the evidence (GRADE approach) was assessed following recommendations from the Cochrane collaboration. Risk ratios were calculated for binary outcomes, mean differences for continuous outcomes. We planned to explore the effects of age, specific anaesthesia regimen, depth of anaesthesia and intraoperative haemodynamic events through subgroup analyses. RESULTS Six RCTs were included. The incidence of postoperative delirium did not differ between groups (4 trials, 557 patients, RR 0.83, 95% CI [0.25, 2.80]), but patients receiving ketamine seemed at lower risk of POCD (3 trials, 163 patients, RR 0.34, 95% CI [0.15, 0.73]). However, both analyses presented limitations. Therefore, the quality of the evidence (GRADE) was deemed low (postoperative delirium) and very low (POCD). CONCLUSION The effect of ketamine on postoperative delirium remains unclear but its administration may offer some protection towards POCD. Large, well-designed randomised trials are urgently needed to further clarify the efficacy of ketamine on neurocognitive outcomes.
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Affiliation(s)
- F. Hovaguimian
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - C. Tschopp
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - B. Beck-Schimmer
- Institute of Anaesthesiology; University of Zurich and University Hospital of Zurich; Zurich Switzerland
| | - M. Puhan
- Epidemiology, Biostatistics and Prevention Institute; University of Zurich; Zurich Switzerland
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Xin X, Xin F, Chen X, Zhang Q, Li Y, Huo S, Chang C, Wang Q. Hypertonic saline for prevention of delirium in geriatric patients who underwent hip surgery. J Neuroinflammation 2017; 14:221. [PMID: 29137628 PMCID: PMC5686947 DOI: 10.1186/s12974-017-0999-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 11/08/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Postoperative delirium (POD) is a common disorder in the elderly patients, and neuroinflammation is the possible underlying mechanism. This study is designed to determine whether or not hypertonic saline (HS) pre-injection can alleviate POD in aged patients. METHODS This prospective study recruited 120 geriatric patients who underwent hip surgery. The patients were randomly divided into two groups: control group (NS group) and HS group. Patients in the NS group were pre-injected with 4 mL/kg isotonic saline, and those in the HS group were pre-injected with 4 mL/kg 7.5% HS. All 120 patients were then subjected to general anesthesia. Blood samples were extracted to detect the concentration of inflammatory factors, namely, IL-1β, IL-6, IL-10, and TNF-α, and the nerve injury factor S100β. Flow cytometry was used to detect the number of monocytes in peripheral venous blood and evaluate the relationship of inflammation to delirium. The nursing delirium screening scale (Nu-DESC) was used to determine cognitive function 1 to 3 days postoperatively. RESULTS Analysis using random-effect multivariable logistic regression indicated that HS administration before anesthesia was associated with a low risk of POD (odds ratio [OR], 0.13; 95% CI, 0.04 to 0.41; P = 0.001) and few CD14 + CD16+ monocytes (β = - 0.61; 95% CI, - 0.74 to - 0.48; P = 0.000) the following day. When the association between HS and delirium was controlled for CD14 + CD16+ monocytes, the effect size became nonsignificant (odds ratio [OR], 0.86; 95% CI, 0.14 to 5.33; P = 0.874). TNF-α was significantly associated with POD (odds ratio [OR], 1.10; 95% CI, 1.05 to 1.16; P = 0.000). However, IL-1β, IL-6, IL-10, and S100β were not significantly related to POD. CONCLUSION HS can alleviate POD in geriatric patients and may inhibit the secretion of inflammatory factors by monocytes.
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Affiliation(s)
- Xi Xin
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Fei Xin
- Department of Respiration, Tianjin Institute of Respiratory Diseases, Tianjin Haihe Hospital, Tianjin Medical University, Tianjin, 300350, People's Republic of China
| | - Xuguang Chen
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yanan Li
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Shuping Huo
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Chongfu Chang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qiujun Wang
- Department of Anesthesiology, The Third Hospital of Hebei Medical University, No 139, Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Ji HM, Han J, Bae HW, Won YY. Combination of measures of handgrip strength and red cell distribution width can predict in-hospital complications better than the ASA grade after hip fracture surgery in the elderly. BMC Musculoskelet Disord 2017; 18:375. [PMID: 28854917 PMCID: PMC5577758 DOI: 10.1186/s12891-017-1738-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 08/25/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early detection of a high-risk patient following hip fracture surgery is of paramount clinical importance. American Society of Anesthesiologists (ASA) grading is an easy and efficient index in predicting a worse outcome. The red cell distribution width (RDW) and handgrip strength, are gaining interest as a prediction tool as well. Accordingly, the objective of this study was to investigate the potential association between ASA, RDW and grip strength and detect the effects of combining RDW and grip strength for predicting early complication after hip fracture surgery in the elderly. METHODS Eighty-three consecutive patients operated with hip fracture surgeries were identified retrospectively. Age, gender, diagnosis, RDW, handgrip strength and ASA grade were recorded. Admission to the intensive care unit (ICU), length of ICU stay, transfer to other departments, in-hospital death, and readmission were investigated as early complications. Logistic regression analysis was applied to evaluate the estimates in predicting complications, and receiver operating characteristics curves were constructed to compare the estimates and decide which method is more accurate. RESULTS After the surgery, 52% of the patients were admitted to the ICU. From the analyses, RDW and grip strength had no significant relation with each other. However, the ICU stay was correlated with RDW and grip strength but not for the ASA grade. A higher ASA grade and grip strength could independently predict ICU admission. The combination of RDW with grip strength outweighed the ASA grade in predictive ability. CONCLUSIONS The current study indicated that combining RDW and grip strength measures can be efficient and clinically relevant in predicting early postoperative complications after fragility hip fracture in the elderly. Due to the objectivity and availability of those two approaches, patient care, and functional outcomes are expected to be improved by adopting these measures in the clinical setting.
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Affiliation(s)
- Hyung-Min Ji
- Department of Joint Surgery, Siheung 21C Hospital, Siheung, South Korea.
| | - Jun Han
- Department of Orthopedics, Ajou University School of Medicine, Suwon, South Korea
| | - Hi-Won Bae
- Department of Orthopedics, Ajou University School of Medicine, Suwon, South Korea
| | - Ye-Yeon Won
- Department of Orthopedics, Ajou University School of Medicine, Suwon, South Korea
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El Hussein M, Hirst S, Osuji J. Professional Socialization: A Grounded Theory of the Clinical Reasoning Processes That RNs and LPNs Use to Recognize Delirium. Clin Nurs Res 2017; 28:321-339. [PMID: 28817952 DOI: 10.1177/1054773817724961] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Delirium is an acute disorder of attention and cognition. It affects half of older adults in acute care settings and is a cause of increasing mortality and costs. Registered nurses (RNs) and licensed practical nurses (LPNs) frequently fail to recognize delirium. The goals of this research were to identify the reasoning processes that RNs and LPNs use to recognize delirium, to compare their reasoning processes, and to generate a theory that explains their clinical reasoning processes. Theoretical sampling was employed to elicit data from 28 participants using grounded theory methodology. Theoretical coding culminated in the emergence of Professional Socialization as the substantive theory. Professional Socialization emerged from participants' responses and was based on two social processes, specifically reasoning to uncover and reasoning to report. Professional Socialization makes explicit the similarities and variations in the clinical reasoning processes between RNs and LPNs and highlights their main concerns when interacting with delirious patients.
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Affiliation(s)
| | | | - Joseph Osuji
- Mount Royal University, Calgary, Alberta, Canada
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Kim S, Kim JJ, Oh J, Park J, Park JY. Delirium characteristics and outcomes in medical and surgical lnpatients: A subgroup analysis. J Crit Care 2017; 43:156-162. [PMID: 28903083 DOI: 10.1016/j.jcrc.2017.08.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 07/20/2017] [Accepted: 08/05/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Persistent delirium can negatively affect patients, increase healthcare costs, and extend the length of hospital stays. This investigation was undertaken to explore associations between patient characteristics and delirium outcomes. MATERIALS AND METHODS Intensive care unit (ICU) and medical and surgical ward inpatients for whom psychiatric consultation was requested for delirium were included in this study. Delirium screening and ongoing assessments were conducted using the Confusion Assessment Method for ICU patients. RESULTS Postoperative delirium developing as a secondary complication following surgery was found to be of significantly longer duration and associated with greater length of hospitalization compared with postoperative delirium attributable to surgery and delirium in medical patients. Medical patients with delirium had lower delirium recovery rates at discharge compared with surgical patients. CONCLUSIONS The findings that patient type and timing of postoperative delirium are associated with differential delirium outcomes suggest that targeted screening and intervention approaches may be needed. Medical patients were more likely to be discharged before recovery from delirium compared with surgical patients. Differences in underlying chronic medical conditions may account for the observed differences in discharge condition between medical and surgical patients with delirium.
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Affiliation(s)
- Sungmin Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae-Jin Kim
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea; Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea
| | - Jooyoung Oh
- Department of Biomedical Science and Engineering, Institute of Integrated Technology, Gwangju Institute of Science and Technology, Gwangju, South Korea
| | - Jaesub Park
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea; Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea.
| | - Jin Young Park
- Institute of Behavioral Science in Medicine, Yonsei University College of Medicine, Seoul, South Korea; Department of Psychiatry, Gangnam Severance Hospital, Yonsei University Health System, Seoul, South Korea.
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Sugano N, Aoyama T, Sato T, Kamiya M, Amano S, Yamamoto N, Nagashima T, Ishikawa Y, Masudo K, Taguri M, Yamanaka T, Yamamoto Y, Matsukawa H, Shiraisi R, Oshima T, Yukawa N, Rino Y, Masuda M. Randomized phase II study of TJ-54 (Yokukansan) for postoperative delirium in gastrointestinal and lung malignancy patients. Mol Clin Oncol 2017; 7:569-573. [PMID: 28855990 PMCID: PMC5574201 DOI: 10.3892/mco.2017.1357] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 07/22/2017] [Indexed: 12/22/2022] Open
Abstract
The present study evaluated the efficacy and safety of TJ-54 (Yokukansan; a traditional Japanese medicine) for the prevention and/or treatment of postoperative delirium in a randomized phase II trial of patients receiving surgery for gastrointestinal and lung malignancies. Patients ≥70 years of age who underwent surgery for gastrointestinal or lung malignancy were eligible for participation in the study. The 186 eligible patients were randomly assigned at a 1:1 ratio to receive TJ-54 or control during their peri-operative care (between 7 days prior to surgery and 4 days following surgery, except for the operation day). The signs and symptoms of delirium were assessed using the Diagnostic and Statistical Manual of Mental Disorders-IV by the investigator during the peri-operative period. A total of 186 eligible gastrointestinal or lung malignancy patients were analyzed (93, TJ-54; 93, control). There were no marked differences between the two randomized groups. The incidence of delirium was 6.5% (6 patients) in the TJ-54 group and 9.7% (9 patients) in the control group, with no significant difference (P=0.419). However, of the patients categorized with a mini-mental state examination (MMSE) score of ≤26, the incidence of postoperative delirium was 9.1% in the TJ-54 group and 26.9% in the control group [risk ratio, 0.338; 95% confidence interval (0.078–1.462), P=0.115]. Treatment with TJ-54 reduced the incidence of postoperative delirium compared with the control group. Although TJ-54 did not demonstrate any contribution to preventing or treating postoperative delirium in patients following surgery for gastrointestinal or lung malignancy, TJ-54 reduced the risk of postoperative delirium in the patients who were classified as MMSE ≤26. Further phase III studies with a larger sample size are required in order to clarify the effects of TJ-54 against postoperative delirium.
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Affiliation(s)
- Nobuhiro Sugano
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Toru Aoyama
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Tsutomu Sato
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Mariko Kamiya
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Shinya Amano
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Naoto Yamamoto
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Takuya Nagashima
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Yoshihiro Ishikawa
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Katsuhiko Masudo
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Masataka Taguri
- Department of Biostatistics, Yokohama City University, Yokohama 236-0004, Japan
| | - Takeharu Yamanaka
- Department of Biostatistics, Yokohama City University, Yokohama 236-0004, Japan
| | - Yuji Yamamoto
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Hiroshi Matsukawa
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Ryuji Shiraisi
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Takashi Oshima
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Norio Yukawa
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Yasushi Rino
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama 236-0004, Japan
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Blandfort S, Gregersen M, Borris LC, Damsgaard EM. Blood transfusion strategy and risk of postoperative delirium in nursing homes residents with hip fracture. A post hoc analysis based on the TRIFE randomized controlled trial. Aging Clin Exp Res 2017; 29:459-466. [PMID: 27251666 DOI: 10.1007/s40520-016-0587-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 05/05/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVES To investigate whether a liberal blood transfusion strategy [Hb levels ≥11.3 g/dL (7 mmol/L)] reduces the risk of postoperative delirium (POD) on day 10, among nursing home residents with hip fracture, compared to a restrictive transfusion strategy [Hb levels ≥9.7 g/dL (6 mmol/L)]. Furthermore, to investigate whether POD influences mortality within 90 days after hip surgery. METHODS This is a post hoc analysis based on The TRIFE - a randomized controlled trial. Frail anemic patients from the Orthopedic Surgical Ward at Aarhus University Hospital were enrolled consecutively between January 18, 2010 and June 6, 2013. These patients (aged ≥65 years) had been admitted from nursing homes for unilateral hip fracture surgery. After surgery, 179 patients were included in this study. On the first day of hospitalization, all enrolled patients were examined for cognitive impairment (assessed by MMSE) and delirium (assessed by CAM). Delirium was also assessed on the tenth postoperative day. RESULTS The prevalence of delirium was 10 % in patients allocated to a liberal blood transfusion strategy (LB) and 21 % in the group with a restrictive blood transfusion strategy (RB). LB prevents development of delirium on day 10, compared to RB, odds ratio 0.41 (95 % CI 0.17-0.96), p = 0.04. Development of POD on day 10 increased the risk of 90-day death, hazard ratio 3.14 (95 % CI 1.72-5.78), p < 0.001. CONCLUSION In nursing home residents undergoing surgery for hip fracture, maintaining hemoglobin level above 11.3 g/dL reduces the rate of POD on day 10 compared to a RB. Development of POD is associated with increased mortality.
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Affiliation(s)
- Sif Blandfort
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark.
| | - Merete Gregersen
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark
| | - Lars Carl Borris
- Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Else Marie Damsgaard
- Department of Geriatrics, Aarhus University Hospital, P.P. Ørumsgade 11, Building 7, 8000, Aarhus C, Denmark
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Abstract
Delirium can be conceptualized as an acute decline in cognitive function that
typically lasts from hours to a few days. Prolonged delirium can also affect
patients with multiple predisposing and/or precipitating factors. In clinical
practice, prolonged delirium is often unrecognized, and can be misdiagnosed as
other psychiatric disorders. We describe a case of a 59-year-old male presenting
with behavioral and cognitive symptoms that was first misdiagnosed as a mood
disorder in a general hospital setting. After prolonged delirium due to multiple
factors was confirmed, the patient was treated accordingly with symptomatic
management. He evolved with progressive improvement of his clinical status.
Early diagnosis and management of prolonged delirium are important to improve
patient prognosis and avoid iatrogenic measures.
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Affiliation(s)
- Fei Cao
- The University of Texas Health Science Center at Houston, USA
| | - Haitham Salem
- The University of Texas Health Science Center at Houston, USA
| | - Caesa Nagpal
- The University of Texas Health Science Center at Houston, USA
| | - Antonio L. Teixeira
- The University of Texas Health Science Center at Houston, USA; The University of Texas Health Science Center at Houston, USA
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Chen W, Ke X, Wang X, Sun X, Wang J, Yang G, Xia H, Zhang L. Prevalence and risk factors for postoperative delirium in total joint arthroplasty patients: A prospective study. Gen Hosp Psychiatry 2017. [PMID: 28622817 DOI: 10.1016/j.genhosppsych.2017.03.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The aim of this prospective study was to investigate the incidence and clinical features of delirium after total joint arthroplasty, and to establish the potential risk factors for postoperative delirium. METHODS A total of 212 consecutive patients undergoing hip or knee arthroplasty, who met the inclusion and exclusive criteria were enrolled. The general characteristics, preoperative and postoperative hematological variables were documented respectively. According to the presence of delirium, all patients were divided into the delirium group and non-delirium group. Univariate and multivariate logistic regression were performed to identify the possible predictors for postoperative delirium. RESULTS At a minimum of 6months of follow-up, 35 patients were observed with postoperative delirium at an estimated total incidence of 16.5%. The incidence of delirium was statistically higher in hip arthroplasty (22.8%) than that in knee arthroplasty (7.1%). The multivariate regression analysis identified older age (OR=1.590, P=0.023), a history of stroke (OR=190.23, P=0.036), preoperative PaO2 (OR=1.277, P=0.018) and equivalent fentanyl dose (OR=1.010, P=0.012) as the predictive factors for postoperative delirium after total joint arthroplasty. CONCLUSIONS The incidence of postoperative delirium after total joint arthroplasty is higher than expected. Based on our findings, we suggest that the surgeons should focus on those patients who have these risk factors and ensure the appropriate management to avoid postoperative delirium.
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Affiliation(s)
- Wenliang Chen
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiurong Ke
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiaoqing Wang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Xiaoliang Sun
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Juncheng Wang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Guojing Yang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Haijie Xia
- Department of anesthesia, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China
| | - Lei Zhang
- Department of adult reconstruction, the third affiliated hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325200, China.
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Yang Y, Zhao X, Dong T, Yang Z, Zhang Q, Zhang Y. Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res 2017; 29:115-126. [PMID: 26873816 DOI: 10.1007/s40520-016-0541-6] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 01/20/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND No formal systematic review or meta-analysis was performed up to now to summarize the risk factors of delirium after hip surgery. AIMS The present study aimed to quantitatively and comprehensively conclude the risk factors of delirium after hip surgery in elderly patients. METHODS A search was applied to CNKI, Embase, Medline, and Cochrane central database (all up to August 2015). All studies assessing the risk factors of delirium after hip surgery in elderly patients without language restriction were reviewed, and qualities of included studies were assessed using the Newcastle-Ottawa Scale. Data were pooled and a meta-analysis was completed. RESULTS A total of 24 studies were selected, which altogether included 5364 patients with hip fracture. One thousand and ninety of them were cases of delirium occurred after surgery, suggesting the accumulated incidence of 24.0 %. Results of meta-analyses showed that elderly patients with preoperative cognitive impairment [odds ratio (OR) 3.21, 95 % confidence interval (CI) 2.26-4.56), advanced age (standardized mean difference 0.50, 95 % CI 0.33-0.67), living in an institution (OR 2.94; 95 % CI 1.65-5.23), heart failure (OR 2.46; 95 % CI 1.72-3.53), total hip arthroplasty (OR 2.21; 95 % CI 1.16-4.22), multiple comorbidities (OR 1.37; 95 % CI 1.12-1.68) and morphine usage (OR 3.01; 95 % CI 1.30-6.94) were more likely to sustain delirium after hip surgery. Females were less likely to develop delirium after hip surgery (OR 0.83; 95 % CI 0.70-0.98). CONCLUSIONS Related prophylaxis strategies should be implemented in elderly patients involved with above-mentioned risk factors to prevent delirium after hip surgery.
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Affiliation(s)
- Yanjiang Yang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Xin Zhao
- Department of Functional and Physical Examination, Hebei General Hospital, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Tianhua Dong
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Zongyou Yang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Qi Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, No. 139 Ziqiang Road, Shijiazhuang, 050051, Hebei, People's Republic of China.
- Key Laboratory of Biomechanics of Hebei Province, Shijiazhuang, 050051, Hebei, People's Republic of China.
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Smith TO, Cooper A, Peryer G, Griffiths R, Fox C, Cross J. Factors predicting incidence of post-operative delirium in older people following hip fracture surgery: a systematic review and meta-analysis. Int J Geriatr Psychiatry 2017; 32:386-396. [PMID: 28093812 DOI: 10.1002/gps.4655] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/01/2016] [Accepted: 12/06/2016] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Delirium is one of the most common complications following hip fracture surgery in older people. This study identified pre- and peri-operative factors associated with the development of post-operative delirium following hip fracture surgery. METHODS Published and unpublished literature were searched to identify all evidence reporting variables on patient characteristics, on-admission, intra-operative and post-operative management assessing incident delirium in older people following hip fracture surgery. Pooled odds ratio (OR) and mean difference of those who experienced delirium compared to those who did not were calculated for each variable. Evidence was assessed using the Downs and Black appraisal tool and interpreted using the GRADE approach. RESULTS A total of 6704 people (2090 people with post-operative delirium) from 32 studies were analysed. There was moderate evidence of nearly a two-times greater probability of post-operative delirium for those aged 80 years and over (OR: 1.77; 95% CI: 1.09, 2.87), whether patients lived in a care institution pre-admission (OR: 2.65; 95% CI: 1.79, 3.92), and a six-times greater probability of developing post-operative delirium with a pre-admission diagnosis of dementia (OR: 6.07, 95% CI: 4.84, 7.62). There was no association with intra-operative variables and probability of delirium. CONCLUSION Clinicians treating people with a hip fracture should be vigilant towards post-operative delirium if their patients are older, have pre-existing cognitive impairment and poorer overall general health. This is also the case for those who experience post-operative complications such as pneumonia or a urinary tract infection. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- T O Smith
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - A Cooper
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - G Peryer
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - R Griffiths
- Department of Anaesthesia, Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, UK
| | - C Fox
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - J Cross
- School of Health Sciences, University of East Anglia, Norwich, UK
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European Society of Anaesthesiology evidence-based and consensus-based guideline on postoperative delirium. Eur J Anaesthesiol 2017; 34:192-214. [DOI: 10.1097/eja.0000000000000594] [Citation(s) in RCA: 491] [Impact Index Per Article: 70.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Suwanpasu S, Grinslade S, Wu YWB, Porock D. Risk factors of delirium in elderly patients with hip fracture. ASIAN BIOMED 2017. [DOI: 10.5372/1905-7415.0802.275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: Delirium is a leading cause of death and disability in the elderly with hip fracture. Identifying reliable risk factors for delirium is critical to support optimal outcomes for prevention and reducing delirium.
Objective: To quantify the reported factors associated to delirium for patients with hip fracture.
Methods: Electronic databases were searched (including Medline, Pub Med, CINAHL, EMBASE, Evidence Based Medicine Reviews, Cochrane Review, Web of Science, and PsycINFO) to identify all studies, published in English language that evaluated the risk factors of delirium hospitalized people with hip fracture. Two reviewers independently assessed methodology quality and extracted relevant data. The data from the included studies were summarized, and pooled estimates were calculated for 12 risk factors.
Results: Thirty-seven studies were included in the review and 25 in the meta-analysis. The incidence of delirium was 32.4% (95% confidence interval [CI] = 25.9%-39.5%). Six predisposing and four precipitating factors predicted delirium among older patients with hip fracture confirmed. The predisposing factors included advanced age (ES = 1.06, 95% CI = 1.03-1.09), male sex (ES = 1.34, 95% CI = 1.08-1.68), impairment of cognition (ES = 2.91, 95% CI = 1.91-4.42), and function (ES = 1.75, 95% CI = 1.39-2.2), comorbidity (ES = 1.59, 95% CI = 1.30-1.96), and health problems (ES = 2.64, 95% CI = 2.04-3.42). Precipitating factors were hypo- or hypernatremia (ES = 1.73, 95% CI = 1.14-2.64), depression (ES = 4.07, 95% CI = 1.95-8.49), more than three prescribed drugs (ES = 1.28, 95% CI = 1.10-1.49), and drugs including opioids (ES = 2.13, 95% CI = 1.42-3.18) and anticholinergic agents (ES = 2.10, 95% CI = 1.60-2.75).
Conclusion: This meta-analysis result provides evidence that these risk factors have a significant impact on delirium in elders with hip fracture during hospitalization. Developing formal screening, and effective preventive and management strategies for delirium is important.
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Affiliation(s)
- Sunee Suwanpasu
- Nursing department, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Susan Grinslade
- University at Buffalo, School of Nursing, New York 14214, United States of America
| | - Yow-Wu B. Wu
- University at Buffalo, School of Nursing, New York 14214, United States of America
| | - Davina Porock
- University at Buffalo, School of Nursing, New York 14214, United States of America
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Perioperative Risk in Patients With Epilepsy Undergoing Total Joint Arthroplasty. J Arthroplasty 2017; 32:537-540. [PMID: 27720235 DOI: 10.1016/j.arth.2016.07.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Revised: 06/30/2016] [Accepted: 07/21/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Epilepsies is a spectrum of brain disorders ranging from severe, life threatening, and disabling to more benign, but little is known about its impact in the perioperative arthroplasty setting. We sought to determine whether epileptic patients undergoing elective total joint arthroplasty (TJA) would be at increased risk for in-hospital complications and death, prolonged stay, and nonroutine discharge. METHODS Using discharge records from the Nationwide Inpatient Sample (2002-2011), we identified 6,054,344 patients undergoing elective primary TJA, of whom 31,865 (0.5%) were identified as having epilepsy. Comparisons of perioperative outcomes were performed by multivariable logistic regression modeling. RESULTS Patients with epilepsy were associated with increased in-hospital mortality (odds ratio [OR] 2.03, 95% confidence interval [CI] 1.57-2.62) and morbidity, including (in decreasing order of magnitude of effect estimate): mechanical ventilation (OR 1.74, 95% CI 1.56-1.94), induced mental disorder (OR 1.70, 95% CI 1.56-1.85), stroke (OR 1.63, 95% CI 1.23-2.15), pneumonia (OR 1.34, 95% CI 1.21-1.49), and ileus or gastrointestinal events (OR 1.26, 95% CI 1.12-1.42). Epilepsy was associated with higher risk for blood transfusion (OR 1.30, 95% CI 1.27-1.33), prolonged hospital stay (OR 1.14, 95% CI 1.11-1.17), and nonroutine discharge (OR 1.54, 95% CI 1.50-1.58). We found no association with inpatient thromboembolic events, acute renal failure, and myocardial infarction. CONCLUSION Patients with epilepsy are at increased risk for early postoperative complications (especially mechanical ventilation, induced mental disorder, and stroke) and resource utilization after elective joint arthroplasty. Greater awareness of epilepsy and its health consequences may contribute to improvements in the perioperative management of TJA patients.
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Asano S, Kunii Y, Hoshino H, Osakabe Y, Shiga T, Itagaki S, Miura I, Yabe H. The efficacy of antipsychotics for prolonged delirium with renal dysfunction. Neuropsychiatr Dis Treat 2017; 13:2823-2828. [PMID: 29180868 PMCID: PMC5695253 DOI: 10.2147/ndt.s147701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
AIM Delirium is commonly encountered in daily clinical practice. To identify predictors influencing outcomes, we retrospectively examined the characteristics of inpatients with delirium who required psychiatric medication during hospitalization. METHODS We extracted all new inpatients (n=523) consulted for psychiatric symptoms at Fukushima Medical University Hospital between October 2011 and September 2013. We selected 203 inpatients with delirium diagnosed by psychiatrists. We analyzed data from 177 inpatients with delirium who received psychiatric medication. We defined an "early improvement group" in which delirium resolved in ≤3 days after starting psychiatric medication, and a "prolonged group" with delirium lasting for >3 days. Among the 83 inpatients with renal dysfunction (estimated glomerular filtration rate <60 mL/min/1.73 m2), we defined an "early improvement group with renal dysfunction" in which delirium resolved in ≤3 days after starting psychiatric medication and a "prolonged group with renal dysfunction" with delirium lasting for >3 days. We then examined differences between groups for different categorical variables. RESULTS Dose of antipsychotic medication at end point was significantly lower in the prolonged group with renal dysfunction than in the early improvement group with renal dysfunction. CONCLUSION The results suggest that maintaining a sufficient dose of antipsychotics from an early stage may prevent prolongation of delirium even in inpatients with renal dysfunction.
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Affiliation(s)
- Satoko Asano
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Yasuto Kunii
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Hiroshi Hoshino
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Yusuke Osakabe
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Tetsuya Shiga
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Shuntaro Itagaki
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Itaru Miura
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
| | - Hirooki Yabe
- Department of Neuropsychiatry, School of Medicine Fukushima Medical University, Fukushima, Japan
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Sheehan KJ, Sobolev B, Chudyk A, Stephens T, Guy P. Patient and system factors of mortality after hip fracture: a scoping review. BMC Musculoskelet Disord 2016; 17:166. [PMID: 27079195 PMCID: PMC4832537 DOI: 10.1186/s12891-016-1018-7] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2015] [Accepted: 04/07/2016] [Indexed: 12/03/2022] Open
Abstract
Background Several patient and health system factors were associated with the risk of death among patients with hip fracture. However, without knowledge of underlying mechanisms interventions to improve survival post hip fracture can only be designed on the basis of the found statistical associations. Methods We used the framework developed by Arksey and O’Malley and Levac et al. for synthesis of factors and mechanisms of mortality post low energy hip fracture in adults over the age of 50 years, published in English, between September 1, 2009 and October 1, 2014 and indexed in MEDLINE. Proposed mechanisms for reported associations were extracted from the discussion sections. Results We synthesized the evidence from 56 articles that reported on 35 patient and 9 system factors of mortality post hip fracture. For 21 factors we found proposed biological mechanisms for their association with mortality which included complications, comorbidity, cardiorespiratory function, immune function, bone remodeling and glycemic control. Conclusions The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. Where reported, underlying mechanisms are often based on a single article and should be confirmed with further study. Therefore, one cannot be certain whether intervening on such factors may produce expected results.
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Affiliation(s)
- K J Sheehan
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
| | - B Sobolev
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - A Chudyk
- Centre for Hip Health and Mobility, Vancouver, Canada
| | - T Stephens
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - P Guy
- Centre for Hip Health and Mobility, Vancouver, Canada.,Department of Orthopaedics, University of British Columbia, Vancouver, Canada
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Jackson TA, Wilson D, Richardson S, Lord JM. Predicting outcome in older hospital patients with delirium: a systematic literature review. Int J Geriatr Psychiatry 2016; 31:392-9. [PMID: 26302258 DOI: 10.1002/gps.4344] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 07/06/2015] [Accepted: 07/17/2015] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Delirium is a serious neuropsychiatric syndrome common in older hospitalised adults. It is associated with poor outcomes, however not all people with delirium have poor outcomes and the risk factors for adverse outcomes within this group are not well described. The objective was to report which predictors of outcome had been reported in the literature. METHODS We performed a systematic review by an initial electronic database search of MEDLINE, Embase and PsycINFO using four key search criteria. These were: (1) participants with a diagnosis of delirium, (2) clearly defined outcome measures, (3) a clearly defined variable as predictor of outcomes and (4) participants in the general hospital, rehabilitation and care home settings, excluding intensive care. Studies were then selected in a systematic fashion using specific predetermined criteria by three reviewers. RESULTS A total of 559 articles were screened, and 57 full text articles were assessed for eligibility. Twenty seven studies describing 18 different predictors of poor outcome were reported. The studies were rated by the Newcastle-Ottawa Score and were generally at low risk of bias. Four broad themes of predictor were identified; five delirium related predictors, two co-morbid psychiatric illness related predictors, eight patient related predictors and three biomarker related predictors. The most numerously described and clinically important appear to be the duration of the delirium episode, a hypoactive motor subtype, delirium severity and pre-existing psychiatric morbidity with dementia or depression. These are all associated with poorer delirium outcomes. CONCLUSION Important predictors of poor outcomes in patients with delirium have been demonstrated. These could be used in clinical practice to focus direct management and guide discussions regarding prognosis. These results also demonstrate a number of key unknowns, where further research to explore delirium prognosis is recommended and is vital to improve understanding and management of this condition.
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Affiliation(s)
- Thomas A Jackson
- School of Immunity and Infection, University of Birmingham, UK.,Department of Geriatric Medicine, University Hospitals Birmingham, UK
| | - Daisy Wilson
- Centre for Musculoskeletal Ageing Research, University of Birmingham, UK
| | | | - Janet M Lord
- School of Immunity and Infection, University of Birmingham, UK.,Centre for Musculoskeletal Ageing Research, University of Birmingham, UK
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Gottschalk A, Hubbs J, Vikani AR, Gottschalk LB, Sieber FE. The Impact of Incident Postoperative Delirium on Survival of Elderly Patients After Surgery for Hip Fracture Repair. Anesth Analg 2016; 121:1336-43. [PMID: 25590791 DOI: 10.1213/ane.0000000000000576] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
BACKGROUND The impact of delirium on survival of elderly patients remains undetermined with conflicting results from clinical studies and meta-analysis. In this study, we assessed the relationship between long-term mortality and incident postoperative delirium in elderly patients undergoing hip fracture repair. METHODS Patients ≥65 years old who were not delirious before undergoing hip fracture repair were included in a database maintained prospectively from March 1999 to July 2009. All participating patients underwent delirium assessment on the second postoperative day by using the confusion assessment method. Survival of the participants was determined as of October 2012. RESULTS In 459 patients, the mean (SD) period of evaluation from surgery until death or study closure was 4.1 (3.5) years with patients followed for as long as 13.6 years. Preoperative cognitive impairment was present in 120 patients (26.1%), and delirium on the second postoperative day was observed in 151 (32.9%) of these patients. Although univariate analysis demonstrated a strong association between incident postoperative delirium and survival, this relationship did not persist in a multivariate model. Survival was a function of age at the time of surgery (P < 0.001), illness severity as determined by the ASA physical status score (P < 0.001), and duration of admission to the intensive care unit after surgery (P < 0.001). Incorporation of incident postoperative delirium did not meaningfully (P = 0.22) enhance the final survival model. In such a model, the hazard ratio (95% confidence interval) for incident postoperative delirium was 1.25 (0.92-1.48). CONCLUSIONS Incident postoperative delirium was not significantly associated with decreased survival in elderly patients undergoing hip fracture repair.
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Affiliation(s)
- Allan Gottschalk
- From the *Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, Baltimore, Maryland; †University of Arizona Health Sciences Center, Tucson, Arizona; ‡School of Medicine, George Washington University, Washington, DC; and §Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Zuo D, Jin C, Shan M, Zhou L, Li Y. A comparison of general versus regional anesthesia for hip fracture surgery: a meta-analysis. Int J Clin Exp Med 2015; 8:20295-20301. [PMID: 26884943 PMCID: PMC4723788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 11/10/2015] [Indexed: 06/05/2023]
Abstract
In this study, we aimed to compare the effect of general versus regional anesthesia on postoperative outcomes in patients undergoing surgical repair of hip fracture. Randomized controlled trials, prospective studies and retrospective observational studies were searched in PubMed, Medline and Embase database published between January 2005 and March 2014. The overall outcome was measured by odds ratios (ORs) and risk ratios (RRs) with their corresponding 95% confidence intervals (CIs). A total of 7 trials, involving 36448 patients received general anesthesia and 33952 patients received regional anesthesia, were included in present meta-analysis. We found that the 30-day mortality rate was lower in general anesthesia cases than that in regional cases (5.3% vs. 6.3%). Overall, our results demonstrated that there was no significant difference in 30-day mortality between two types of anesthesia in patients with hip fracture surgery (RR=0.98, 95% CI=0.92-1.04, P=0.48), indicating that types of anesthesia might not be a risk factor for hip fracture surgery. No statistically significant difference was observed in other outcome measures (P>0.05). In conclusion, our results suggested that the choice of anesthesia (general or regional) should be made by the anesthesiologist on an individual basis and based on the patient's medical conditions. Further research is still needed to evaluate the effect of these two anesthesia methods.
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Affiliation(s)
- Di Zuo
- Operation Room, 2nd Hospital of Haerbin Medical University Haerbin 150001, Heilongjiang, P. R. China
| | - Chunyu Jin
- Operation Room, 2nd Hospital of Haerbin Medical University Haerbin 150001, Heilongjiang, P. R. China
| | - Minhong Shan
- Operation Room, 2nd Hospital of Haerbin Medical University Haerbin 150001, Heilongjiang, P. R. China
| | - Lijuan Zhou
- Operation Room, 2nd Hospital of Haerbin Medical University Haerbin 150001, Heilongjiang, P. R. China
| | - Yanshuang Li
- Operation Room, 2nd Hospital of Haerbin Medical University Haerbin 150001, Heilongjiang, P. R. China
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