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Aldecoa C, Bettelli G, Bilotta F, Sanders RD, Aceto P, Audisio R, Cherubini A, Cunningham C, Dabrowski W, Forookhi A, Gitti N, Immonen K, Kehlet H, Koch S, Kotfis K, Latronico N, MacLullich AMJ, Mevorach L, Mueller A, Neuner B, Piva S, Radtke F, Blaser AR, Renzi S, Romagnoli S, Schubert M, Slooter AJC, Tommasino C, Vasiljewa L, Weiss B, Yuerek F, Spies CD. Update of the European Society of Anaesthesiology and Intensive Care Medicine evidence-based and consensus-based guideline on postoperative delirium in adult patients. Eur J Anaesthesiol 2024; 41:81-108. [PMID: 37599617 PMCID: PMC10763721 DOI: 10.1097/eja.0000000000001876] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/22/2023]
Abstract
Postoperative delirium (POD) remains a common, dangerous and resource-consuming adverse event but is often preventable. The whole peri-operative team can play a key role in its management. This update to the 2017 ESAIC Guideline on the prevention of POD is evidence-based and consensus-based and considers the literature between 01 April 2015, and 28 February 2022. The search terms of the broad literature search were identical to those used in the first version of the guideline published in 2017. POD was defined in accordance with the DSM-5 criteria. POD had to be measured with a validated POD screening tool, at least once per day for at least 3 days starting in the recovery room or postanaesthesia care unit on the day of surgery or, at latest, on postoperative day 1. Recent literature confirmed the pathogenic role of surgery-induced inflammation, and this concept reinforces the positive role of multicomponent strategies aimed to reduce the surgical stress response. Although some putative precipitating risk factors are not modifiable (length of surgery, surgical site), others (such as depth of anaesthesia, appropriate analgesia and haemodynamic stability) are under the control of the anaesthesiologists. Multicomponent preoperative, intra-operative and postoperative preventive measures showed potential to reduce the incidence and duration of POD, confirming the pivotal role of a comprehensive and team-based approach to improve patients' clinical and functional status.
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Affiliation(s)
- César Aldecoa
- From the Department of Anaesthesia and Postoperative Critical Care, Hospital Universitario Rio Hortega, Valladolid, Spain (CA), Department of Biomedical Studies, University of the Republic of San Marino, San Marino (GB), Department of Anesthesiology, Critical Care and Pain Medicine, 'Sapienza' University of Rome, Rome, Italy (FB, AF, LM), Specialty of Anaesthetics & NHMRC Clinical Trials Centre, University of Sydney & Department of Anaesthetics and Institute of Academic Surgery, Royal Prince Alfred Hospital (RDS), Department of Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and Humboldt Universität zu Berlin, Campus Charité Mitte, and Campus Virchow Klinikum (CDS, SK, AM, BN, LV, BW, FY), Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy (PA), Dipartimento di Scienze Biotecnologiche di Base, Cliniche Intensivologiche e Perioperatorie, Università Cattolica del Sacro Cuore, Rome, Italy (PA), Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Göteborg, Sweden (RA), Geriatria, Accettazione Geriatrica e Centro di ricerca per l'invecchiamento, IRCCS INRCA, Ancona, Italy (AC), School of Biochemistry and Immunology and Trinity College Institute of Neuroscience, Trinity College, Dublin, Ireland (CC), First Department of Anaesthesiology and Intensive Care Medical University of Lublin, Poland (WD), Research Unit of Nursing Science and Health Management, University of Oulu, Oulu, Finland (KI), Section of Surgical Pathophysiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (HK), Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University in Szczecin, Poland (KK), Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia (NG, NL, SP, SR), Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy (NL, SP), Edinburgh Delirium Research Group, Ageing and Health, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom (AMJM), Department of Anaesthesia and Intensive Care, Nykoebing Hospital; University of Southern Denmark, SDU (SK, FR), Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia (ARB), Center for Intensive Care Medicine, Luzerner Kantonsspital, Lucerne, Switzerland (ARB), Department of Health Science, Section of Anesthesiology, University of Florence (SR), Department of Anaesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy (SR), School of Health Sciences, Institute of Nursing, ZHAW Zurich University of Applied Science, Winterthur, Switzerland (MS), Departments of Psychiatry and Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands (AJCS), Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium (AJCS) and Dental Anesthesia and Intensive Care Unit, Polo Universitario Ospedale San Paolo, Department of Biomedical, Surgical and Odontoiatric Sciences, University of Milano, Milan, Italy (CT)
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Zarour S, Weiss Y, Kiselevich Y, Iacubovici L, Karol D, Shaylor R, Davydov T, Matot I, Cohen B. The association between midazolam premedication and postoperative delirium - a retrospective cohort study. J Clin Anesth 2024; 92:111113. [PMID: 37280146 DOI: 10.1016/j.jclinane.2023.111113] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 02/17/2023] [Accepted: 03/17/2023] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE To evaluate the association between midazolam premedication and postoperative delirium in a large retrospective cohort of patients ≥70 years. DESIGN Retrospective cohort study. SETTING A single tertiary academic medical center. PATIENTS Patients ≥70 years having elective non-cardiac surgery under general anesthesia from 2020 to 2021. INTERVENTIONS Midazolam premedication, defined as intravenous midazolam administration prior to induction of general anesthesia. MEASUREMENTS The primary outcome, postoperative delirium, was a collapsed composite outcome including at least one of the following: a positive 4A's test during post-anesthesia care unit stay and/or the initial 2 postoperative days; physician or nursing records reporting new-onset confusion as captured by the CHART-DEL instrument; or a positive 3D-CAM test. The association between midazolam premedication and postoperative delirium was assessed using multivariable logistic regression, adjusting for potential confounding variables. As secondary analysis, we investigated the association between midazolam premedication and a composite of other postoperative complications. Several sensitivity analyses were performed using similar regression models. MAIN RESULTS In total, 1973 patients were analyzed (median age 75 years, 47% women, 50% ASA score ≥ 3, 32% high risk surgery). The overall incidence of postoperative delirium was 15.3% (302/1973). Midazolam premedication was administered to 782 (40%) patients (median [IQR] dose 2 [1,2] mg). After adjustment for potential confounding variables, midazolam premedication was not associated with increased odds of postoperative delirium, with adjusted odds ratio of 1.09 (95% confidence interval 0.82-1.45; P = 0.538). Midazolam premedication was also not associated with the composite of other postoperative complications. Furthermore, no association was found between midazolam premedication and postoperative delirium in any of the sensitivity analyses preformed. CONCLUSIONS Our results suggest that low doses of midazolam can be safely used to pre-medicate elective surgical patients 70 years or older before non-cardiac surgery, without significant effect on the risk of developing postoperative delirium.
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Affiliation(s)
- Shiri Zarour
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yotam Weiss
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Yossef Kiselevich
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Liat Iacubovici
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Dana Karol
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Ruth Shaylor
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Tamara Davydov
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Idit Matot
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel
| | - Barak Cohen
- Division of Anesthesia, Intensive Care, and Pain Management, Tel-Aviv Medical Center, Tel-Aviv University, Tel-Aviv, Israel; Outcomes Research Consortium, Cleveland, OH, United States of America.
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Igwe EO, Nealon J, O'Shaughnessy P, Bowden A, Chang HCR, Ho MH, Montayre J, Montgomery A, Rolls K, Chou KR, Chen KH, Traynor V, Smerdely P. Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis. Worldviews Evid Based Nurs 2023. [PMID: 37128953 DOI: 10.1111/wvn.12649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/05/2023] [Accepted: 03/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND With the increase in life expectancy around the globe, the incidence of postoperative delirium (POD) among older people (≥65 years) is growing. Previous studies showed a wide variation in the incidence of POD, from 4% to 53%, with a lack of specific evidence about the incidence of POD by specific surgery type among older people. The aim of this systematic review and meta-analysis was to determine the incidence of POD by surgery type within populations 65 years and over. METHODS Databases including PubMed, Cochrane library, Embase, and CINAHL were searched until October 2020. Due to the relatively higher number of meta-analyses undertaken in this area of research, a streamlined systematic meta-analysis was proposed. RESULTS A total of 28 meta-analyses (comprising 284 individual studies) were reviewed. Data from relevant individual studies (n = 90) were extracted and included in the current study. Studies were grouped into eight surgery types and the incidence of POD for orthopedic, vascular, spinal, cardiac, colorectal, abdominal, urologic, and mixed surgeries was 20%, 14%, 13%, 32%, 14%, 30%, 10%, and 26%, respectively. POD detection instruments were different across the studies, with Confusion Assessment Method (CAM & CAM-ICU) being the most frequently adopted. LINKING EVIDENCE TO ACTION This study showed that POD incidence in older people undergoing surgery varied widely across surgery type. The more complex surgeries like cardiac and abdominal surgeries were associated with a higher risk of POD. This highlights the need to include the level of surgery complexity as a risk factor in preoperative assessments.
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Affiliation(s)
- Ezinne Oyidia Igwe
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Jessica Nealon
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Medicine, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Pauline O'Shaughnessy
- School of Mathematics and Applied Statistics, Faculty of Engineering and Information Sciences, University of Wollongong, Wollongong, New South Wales, Australia
| | - Alera Bowden
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Hui-Chen Rita Chang
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
- School of Nursing and Midwifery, Western Sydney University, Penrith, New South Wales, Australia
| | - Mu-Hsing Ho
- School of Nursing, LKS Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
| | - Jed Montayre
- School of Nursing, Hong Kong Polytechnic University, Hung Hom, Hong Kong SAR
| | - Amy Montgomery
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Kaye Rolls
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Kuei-Ru Chou
- School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Department of Nursing, Taipei Medical University-Shuang Ho Hospital, New Taipei, Taiwan
- Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
- Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan
- Center for Nursing and Healthcare Research in Clinical Practice Application, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
- Evidence-based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Victoria Traynor
- School of Nursing, Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
- Illawarra Health and Medical Research Institute (IHMRI), Wollongong, New South Wales, Australia
| | - Peter Smerdely
- School of Population Health, UNSW Medicine, Sydney, New South Wales, Australia
- St George Hospital, Kogarah, New South Wales, Australia
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Kotani T, Ida M, Inoue S, Naito Y, Kawaguchi M. Association between Preoperative Hand Grip Strength and Postoperative Delirium after Cardiovascular Surgery: A Retrospective Study. J Clin Med 2023; 12:jcm12072705. [PMID: 37048787 PMCID: PMC10095472 DOI: 10.3390/jcm12072705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 04/09/2023] Open
Abstract
The association of frailty with postoperative delirium has not been fully investigated in patients undergoing cardiovascular surgery. Therefore, this study aimed to investigate whether preoperative hand grip strength is associated with postoperative delirium. This retrospective study included patients aged >65 years who had undergone elective cardiovascular surgery using cardiopulmonary bypass at a Japanese university hospital between April 2020 and February 2022. We defined low hand grip strength as hand grip values of <275 n and <177 n for men and women, respectively. Postoperative delirium was assessed using the confusion assessment method during patients’ intensive care unit stay. The odds ratio of low hand grip strength for postoperative delirium was estimated using multiple logistic analysis, which was adjusted for prominent clinical factors. Ninety-five patients with a median age of 74 years were included in the final analysis, and 31.5% of them had low hand grip strength. Postoperative delirium occurred in 37% of patients, and the odds ratio of low preoperative hand grip strength for postoperative delirium was 4.58 (95% confidence interval: 1.57–13.2). Thirty-seven patients experienced postoperative delirium after cardiovascular surgery using cardiopulmonary bypass, and low preoperative hand grip strength was positively associated with its occurrence.
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Affiliation(s)
- Taichi Kotani
- Department of Anesthesiology, Nara Medical University, Kashihara 634-8522, Japan
| | - Mitsuru Ida
- Department of Anesthesiology, Nara Medical University, Kashihara 634-8522, Japan
| | - Satoki Inoue
- Department of Anesthesiology, Fukushima Medical University, Fukushima 960-1295, Japan
| | - Yusuke Naito
- Department of Anesthesiology, Nara Medical University, Kashihara 634-8522, Japan
| | - Masahiko Kawaguchi
- Department of Anesthesiology, Nara Medical University, Kashihara 634-8522, Japan
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Arita A, Takahashi H, Ogino T, Miyoshi N, Uemura M, Akasaka H, Sugimoto K, Rakugi H, Doki Y, Eguchi H. Grip strength as a predictor of postoperative delirium in patients with colorectal cancers. Ann Gastroenterol Surg 2022; 6:265-272. [PMID: 35261952 PMCID: PMC8889853 DOI: 10.1002/ags3.12519] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/01/2021] [Accepted: 10/04/2021] [Indexed: 01/01/2023] Open
Abstract
Background The population is aging rapidly, and the population of patients who undergo surgeries is aging, too. Elderly patients have much risk of postoperative delirium, which increases the number of adverse events. The aim of this study was to investigate the risk factors of postoperative delirium in elderly patients with colorectal cancer. Methods We conducted a retrospective cohort analysis of consecutive patients aged 70 years and older who underwent surgeries for colorectal cancer at our department in the period from May 2012 to October 2019. We investigated the correlation between the incidence of postoperative delirium and Comprehensive Geriatric Assessment (CGA) scores, comorbidities, and perioperative factors. Postoperative delirium was retrospectively diagnosed by checking clinical records. Results Postoperative delirium was diagnosed in 36 of 271 patients (13.3%) with colorectal cancer. Among many comorbidities, only renal disease was significantly associated with postoperative delirium. Among the items in the CGA, age; Mini-Mental State Exam (MMSE), Barthel Index, Instrumental Activities of Daily Living (IADL), Vitality Index, and Geriatric Depression Scale (GDS) scores; and grip strength were associated with postoperative delirium. Among perioperative factors, blood transfusion was associated with postoperative delirium. Multivariate logistic regression analysis identified older age, MMSE, GDS, and grip strength as significant independent risk factors for postoperative delirium. Conclusions This single-center retrospective observational study demonstrated that grip strength is an independent predictor of postoperative delirium, along with age, MMSE, and GDS.
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Affiliation(s)
- Asami Arita
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Hidekazu Takahashi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Takayuki Ogino
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Norikatsu Miyoshi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Mamoru Uemura
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Hiroshi Akasaka
- Department of Geriatric and General MedicineGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Ken Sugimoto
- Department of General and Geriatric MedicineGraduate School of MedicineKawasaki Medical SchoolKurashiki CityJapan
| | - Hiromi Rakugi
- Department of Geriatric and General MedicineGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Yuichiro Doki
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
| | - Hidetoshi Eguchi
- Department of Gastroenterological SurgeryGraduate School of MedicineOsaka UniversitySuita CityJapan
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The assessment of risk factors for postoperative delirium using cubic spline curves in gastroenterological surgery. Surg Today 2021; 51:1969-1977. [PMID: 34562176 DOI: 10.1007/s00595-021-02379-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 03/25/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE Delirium is associated with longer hospital stays and increased medical costs and mortality. This study explored the risk factors for postoperative delirium in gastroenterological surgery and investigated the association between qualitative changes in risk factors and the incidence of postoperative delirium. METHODS A total of 418 patients > 18 years old who underwent gastroenterological surgery at our department between April 2018 and September 2019 were included. Risk factors were identified by comparing patients with and without postoperative delirium. Continuous variables were evaluated graphically using cubic spline curves. A logistic regression analysis was performed to assess independent risk factors. RESULTS The incidence of postoperative delirium was 6.9%. The cubic spline curve showed that the incidence of postoperative delirium began to increase at 50 years old and increased sharply at 70 years old. A multiple logistic regression analysis of patients > 50 years old identified 5 risk factors: age ≥ 70 years, preoperative serum albumin ≤ 3.8 g/dL, psychosis, sedative-hypnotics, and intensive-care unit admission. CONCLUSION The risk of postoperative delirium increases progressively at 50 years old and sharply at 70 years old. Advanced age, preoperative hypoalbuminemia, psychosis, sedative-hypnotics, and intensive-care unit admission are risk factors for postoperative delirium in patients > 50 years old undergoing gastroenterological surgery.
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Lee D, Petersen F, Wu M, Chapman G, Hayman M, Tomkins K, Fernando J. A prospective observational cohort pilot study of the association between midazolam use and delirium in elderly endoscopy patients. BMC Anesthesiol 2021; 21:53. [PMID: 33593276 PMCID: PMC7885452 DOI: 10.1186/s12871-021-01275-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 02/08/2021] [Indexed: 12/19/2022] Open
Abstract
Background Midazolam is a benzodiazepine commonly used in procedural sedation and general anaesthesia. Current anaesthetic guidelines advise the avoidance of benzodiazepines in elderly patients due to concerns of an increased risk of delirium. Delirium is associated with significant patient morbidity and mortality, while also increasing health costs. Despite this, midazolam is often used in elderly patients undergoing low risk procedures due to the benefits of rapid onset, anxiolysis and haemodynamic stability compared to other sedatives. To date, studies describing the relationship between midazolam use and delirium in elderly patients undergoing low risk procedures, such as endoscopy, are limited. Method This was a prospective observational cohort pilot study identifying the prevalence of delirium pre-procedure and incidence of delirium post-procedure in elderly endoscopy patients receiving midazolam. The study population was elderly patients greater than 65 years of age, without underlying cognitive dysfunction, undergoing elective endoscopy. Electronic databases were used for collection of demographic and clinical information. Delirium was identified through the administration of the Family Confusion Assessment Method survey; this was administered to carers of the study population 24–48 h pre and post procedure to categorically identify the presence or absence of delirium. Results Fifty-eight participants were recruited for this study and eighteen were subsequently excluded based upon additional exclusion criteria. Forty patients were included in the final results. American Society of Anaesthesiology Classification (ASA) of patients were as follows: 1 (9 patients), 2 (12 Patients), 3 (16 Patients) and 4 (3 patients). Patients underwent gastroscopy, colonoscopy or combined gastroscopy and colonoscopy. This study identified no cases of delirium in elderly patients after administration of midazolam for elective endoscopy procedures 24–48 h post-procedure. Additionally, a high proportion of elderly patients were found to have received midazolam. Conclusion No episodes of delirium were identified in this study. This finding runs counter to current guideline recommendations regarding midazolam use in the elderly patient and that elderly patients undergoing elective endoscopy represent a significantly different patient population compared to those previously studied. This study suggests that in the study population that the risk of delirium in patients exposed to midazolam in elective endoscopy was not demonstrated and that it may be safe to perform experimental studies to elucidate the safety of midazolam in larger studies.
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Affiliation(s)
- Dickson Lee
- Rockhampton Hospital, Central Queensland Hospital and Health Service, Canning Street, Rockhampton, QLD, 4700, Australia.
| | - Fiona Petersen
- Rockhampton Hospital, Central Queensland Hospital and Health Service, Canning Street, Rockhampton, QLD, 4700, Australia
| | - Maurice Wu
- The University of Queensland Rural Clinical School, 78 Canning St, The Range, QLD, 4700, Australia
| | - Gwenda Chapman
- The University of Queensland Rural Clinical School, 78 Canning St, The Range, QLD, 4700, Australia
| | - Melanie Hayman
- Central Queensland University, 554-700 Yaamba Rd, Norman Gardens, QLD, 4701, Australia
| | - Kerrilyn Tomkins
- Central Queensland University, 554-700 Yaamba Rd, Norman Gardens, QLD, 4701, Australia
| | - Jeremy Fernando
- The University of Queensland Rural Clinical School, 78 Canning St, The Range, QLD, 4700, Australia.,St Vincent's Hospital, 22-36 Scott St, Toowoomba City, QLD, 4350, Australia
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Ristescu AI, Pintilie G, Moscalu M, Rusu D, Grigoras I. Preoperative Cognitive Impairment and the Prevalence of Postoperative Delirium in Elderly Cancer Patients-A Prospective Observational Study. Diagnostics (Basel) 2021; 11:275. [PMID: 33578953 PMCID: PMC7916677 DOI: 10.3390/diagnostics11020275] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 01/26/2021] [Accepted: 02/07/2021] [Indexed: 11/17/2022] Open
Abstract
Preoperative cognitive impairment (PCI) in cancer patients includes a broad spectrum of neurocognitive changes produced by complex interplay of patient, tumoural and treatment-related factors. Reduced preoperative cognitive reserve can favour the emergence of postoperative delirium (POD). The study aims to document PCI prevalence and to assess the relationship with POD in elderly cancer patients. The prospective observational study included consecutive patients scheduled for elective surgery; PCI was assessed with Mini-Cog test and defined at a score ≤ 3, POD was screened using Nursing Delirium Screening Scale (Nu-DESC) and defined at a score ≥ 2. Data on education, American Society of Anesthesiologists (ASA) score, preoperative medications, substance use, comorbidities, sensorial deficits, surgery and anaesthesia type, anaesthetic drugs, Mini-Cog score, postoperative pain, Nu-DESC were collected. In total, 131 patients were enrolled, mean age 72.1 ± 5.9 years. PCI prevalence was 51.9% (n = 68). POD prevalence was 19.8% (n = 26), with significantly higher value in PCI patients (27.9% vs. 11.1%, p = 0.016). In multivariate analysis, Mini-Cog score ≤ 3 (OR = 2.6, p = 0.027), clock draw (OR: 2.9, p = 0.013), preoperative renal dysfunction (OR = 2.6, p = 0.012), morphine (OR = 2.7, p = 0.007), metoclopramide (OR = 6.6, p = 0.006), and high pain score (OR = 1.8, p = 0.018) had a significant association with POD development. In this sample of elderly patients, PCI had a high prevalence and predicted the emergence of POD. Incorporating Mini-Cog test into the preoperative evaluation of onco-geriatric patients seems valuable and feasible.
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Affiliation(s)
- Anca Irina Ristescu
- Department of Anaesthesia and Intensive Care, School of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.I.R.); (G.P.); (I.G.)
- Department of Anaesthesia and Intensive Care, Regional Institute of Oncology, 700483 Iasi, Romania;
| | - Georgiana Pintilie
- Department of Anaesthesia and Intensive Care, School of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.I.R.); (G.P.); (I.G.)
| | - Mihaela Moscalu
- Department of Preventive Medicine and Interdisciplinarity, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Daniel Rusu
- Department of Anaesthesia and Intensive Care, Regional Institute of Oncology, 700483 Iasi, Romania;
| | - Ioana Grigoras
- Department of Anaesthesia and Intensive Care, School of Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania; (A.I.R.); (G.P.); (I.G.)
- Department of Anaesthesia and Intensive Care, Regional Institute of Oncology, 700483 Iasi, Romania;
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Impact of delirium in acute cardiac care unit after transcatheter aortic valve replacement. Int J Cardiol 2021; 330:164-170. [PMID: 33529663 DOI: 10.1016/j.ijcard.2021.01.053] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/12/2021] [Accepted: 01/24/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delirium is a cognitive disorder that commonly occurs during hospitalization in acute cardiac care units (ACCU), but its effect after transcatheter aortic valve replacement (TAVR) has not been well evaluated. The objective of this study is to determine the incidence, predictive factors and prognostic impact of delirium following TAVR. METHODS A total of 501 consecutive patients admitted to an ACCU after TAVR were included. The Confusion Assessment Method was used to evaluate delirium during ACCU stay. Risk factors, preventive pharmacological treatment, peri-procedural characteristics and complications were assessed. Clinical events were recorded with a median follow-up of 24 months. RESULTS The incidence of delirium after TAVR was 22.0% (n = 110). Previous cognitive impairment (OR 4.17; 95% CI 1.11-15.71; p = 0.035), peripheral arterial disease (OR 4.54; 95% CI 1.79-11.54; p = 0.001), the use of general anaesthesia (OR 2.55; 95% CI 1.32-4.90; p = 0.005), and prolonged mechanical ventilation (OR 18.86; 95% CI 1.85-192.58; p = 0.013) were significantly associated with the development of delirium. Patients with delirium had a greater hospital length of stay (7.5 [5.5-13.5] vs 5.6 [4.6-8.2] days, mean difference - 3.49; 95% CI -5.45 to -1.52; p < 0.001), and higher in-hospital (OR 2.68; 95% CI 1.02-6.99; p = 0.045), 1-year (HR 2.09; 95% CI 1.13-3.87; p = 0.018) and 2-year mortality (HR 1.94; 95% CI 1.12-3.34; p = 0.017). CONCLUSIONS Delirium is a frequent complication in patients admitted to ACCU after TAVR, and is associated with prolonged hospital stay and higher in-hospital and mid-term mortality.
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Jung C, Hinken L, Fischer-Kumbruch M, Trübenbach D, Fielbrand R, Schenk I, Diegmann O, Krauß T, Scheinichen D, Schultz B. Intraoperative monitoring parameters and postoperative delirium: Results of a prospective cross-sectional trial. Medicine (Baltimore) 2021; 100:e24160. [PMID: 33429798 PMCID: PMC7793381 DOI: 10.1097/md.0000000000024160] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 12/10/2020] [Indexed: 01/05/2023] Open
Abstract
Postoperative delirium (PODE) can be associated with severe clinical complications; therefore, preventive measures are important. The objective of this trial was to elucidate whether haemodynamic or electroencephalographic (EEG) monitoring parameters during general anaesthesia or sevoflurane dosage correlate with the incidence of PODE. In addition, sevoflurane dosages and EEG stages during the steady state of anaesthesia were analyzed in patients of different ages.Eighty adult patients undergoing elective abdominal surgery received anaesthesia with sevoflurane and sufentanil according to the clinical routine. Anaesthesiologists were blinded to the EEG. Haemodynamic parameters, EEG parameters, sevoflurane dosage, and occurrence of PODE were analyzed.Thirteen patients (4 out of 33 women, 9 out of 47 men) developed PODE. Patients with PODE had a greater mean arterial pressure (MAP) variance (267.26 (139.40) vs 192.56 (99.64) mmHg2, P = .04), had a longer duration of EEG burst suppression or suppression (27.09 (45.32) vs 5.23 (10.80) minutes, P = .03), and received higher minimum alveolar sevoflurane concentrations (MAC) (1.22 (0.22) vs 1.09 (0.17), P = .03) than patients without PODE. MAC values were associated with wide ranges of EEG index values representing different levels of hypnosis.The results suggest that, in order to prevent PODE, a great variance of MAP, higher doses of sevoflurane, and deep levels of anaesthesia should be avoided. Titrating sevoflurane according to end-tidal gas monitoring and vital signs can lead to unnecessarily deep or light hypnosis. Intraoperative EEG monitoring may help to prevent PODE.
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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: 73] [Impact Index Per Article: 24.3] [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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Edwards DA, Medhavy A, Hoffman OG, Hoffman GR. Postoperative Delirium is Associated With Prolonged Head and Neck Resection and Reconstruction Surgery: An Institutional Study. J Oral Maxillofac Surg 2020; 79:249-258. [PMID: 32898481 DOI: 10.1016/j.joms.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 08/07/2020] [Accepted: 08/07/2020] [Indexed: 12/16/2022]
Abstract
PURPOSE Delirium is a recognized complication of surgery. It has a deleterious effect on a patient's postoperative recovery and well-being. The purpose of this study was to estimate the frequency and identify the risk factors for the development of postoperative delirium (POD) in a cohort of patients who underwent extensive head and neck surgery (HNS) of greater than five hours duration. MATERIALS AND METHODS The authors undertook a retrospective cohort study of patients who underwent HNS of greater than five hours duration. The primary predictor variables comprised a set of risk factors (sociodemographic, disease-specific, duration of surgery, and duration of inpatient stay) that were thought to be associated with the development of POD. The primary outcome variable was the development of POD. Descriptive, bivariate, and multivariate statistical analysis was undertaken, and significance was set at P < .05. RESULTS One hundred and seventy patients were included in the study. There were 124 males and 46 females. Forty patients (23.53%) developed POD: 30 documented and 10 inferred. The mean age of the POD cohort was 65 years (SD 13), with a median age of 69 years. The occurrence of POD was statistically related to increased age, mental health status, American Society of Anesthesiologists (ASA) score, and drug dependence (either illicit or prescription). POD and operative duration were statistically associated. POD and length of stay were not statistically associated. CONCLUSION Delirium did occur postoperatively in 23.53% of our patients who underwent extensive and prolonged HNS. POD may go unrecognized by treating teams. As POD has a deleterious effect on the cognitive function, it is important to identify and aggressively treat episodes of POD that occur during a patient's postoperative recovery.
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Affiliation(s)
- Delyth A Edwards
- Consultant (Attending) Anaesthetist, Department of Anaesthetics, John Hunter Hospital, Newcastle, Australia
| | - Aditi Medhavy
- Resident Medical Officer, Liverpool Hospital, Liverpool, Australia
| | - Olivia G Hoffman
- First year Medical Student, The University of Melbourne, Melbourne, Australia
| | - Gary R Hoffman
- Consultant (Attending) in Head and Neck Surgery, Department of Maxillofacial Surgery, John Hunter Hospital, Newcastle, Australia; Professor, Medical School, The University of Newcastle, Newcastle, Australia.
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Aung Thein MZ, Pereira JV, Nitchingham A, Caplan GA. A call to action for delirium research: Meta-analysis and regression of delirium associated mortality. BMC Geriatr 2020; 20:325. [PMID: 32894065 PMCID: PMC7487610 DOI: 10.1186/s12877-020-01723-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 08/19/2020] [Indexed: 12/19/2022] Open
Abstract
Background Delirium is an extremely common hospital complication. No study to date has assessed whether a priori defined covariates; type of hospital setting and year of study publication, influence the relationship between delirium and mortality. This is also the first study to examine the longitudinal trend of delirium-associated mortality over recent decades, to analyse the trajectory of our efforts in combating this disease. Methods MEDLINE, EMBASE and PsycINFO, were searched from January 1981 to May 2018 for English-language primary articles. Rigorous title and abstract screen and full-text screen were conducted independently by two reviewers. This paper adhered to MOOSE guidelines. Data was extracted independently by one reviewer using standardised data-collection sheets, with a separate reviewer verifying for accuracy. The quality of included studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Unadjusted effect sizes and event counts were analysed with a random effects model in primary meta-analysis and meta-regression, whereas a mixed effect model was used in secondary sub-group analysis. Mortality data at longest follow-up and cumulative mortality (hospital mortality combined with mortality at longest follow-up) data were analysed. Results As part of a larger project, 446 of 6790 articles were retrieved, including 71 studies that measured mortality. Our results demonstrate that elderly inpatients with delirium had significantly greater odds of mortality (OR 3.18 [95%CI: 2.73, 3.70]) compared to non-delirious controls. Patients with delirium in the ICU had the highest odds for mortality (OR: 7.09 [95%CI: 3.60, 14.0]); double the risk compared to the average. Curiously, despite advancements in delirium research, delirium associated in-hospital odds of mortality has not changed in 30 years. Conclusion This is the largest meta-analysis to confirm the association between delirium and mortality, in older (age ≥ 65) hospital inpatients. The current meta-analysis highlights the significant odds of mortality after an episode of delirium, and these odds are much higher for ICU patients. However, in contrast to other medical conditions that have seen a decrease in associated mortality over the past few decades, delirium associated mortality remains unchanged. These findings underscore the urgent need for better delirium treatments. PROSPERO Registration Number: CRD42018098627, https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=98627
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Affiliation(s)
- May Zin Aung Thein
- Faculty of Medicine, University of New South Wales, Edmund Blackett Building, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia.
| | - Jarett V Pereira
- Faculty of Medicine, University of New South Wales, Edmund Blackett Building, Prince of Wales Hospital, Barker Street, Randwick, NSW, 2031, Australia
| | - Anita Nitchingham
- Department of Geriatric Medicine, Prince of Wales Hospital, Prince of Wales Clinical School University of New South Wales, Sydney, Australia
| | - Gideon A Caplan
- Department of Geriatric Medicine, Prince of Wales Hospital, Prince of Wales Clinical School University of New South Wales, Sydney, Australia
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Khadaroo RG, Warkentin LM, Wagg AS, Padwal RS, Clement F, Wang X, Buie WD, Holroyd-Leduc J. Clinical Effectiveness of the Elder-Friendly Approaches to the Surgical Environment Initiative in Emergency General Surgery. JAMA Surg 2020; 155:e196021. [PMID: 32049271 DOI: 10.1001/jamasurg.2019.6021] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Older adults, especially those with frailty, have a higher risk for complications and death after emergency surgery. Acute Care for the Elderly models have been successful in medical wards, but little evidence is available for patients in surgical wards. Objectives To develop and assess the effect of an Elder-Friendly Approaches to the Surgical Environment (EASE) model in an emergency surgical setting. Design, Setting, and Participants This prospective, nonrandomized, controlled before-and-after study included patients 65 years or older who presented to the emergency general surgery service of 2 tertiary care hospitals in Alberta, Canada. Transfers from other medical services, patients undergoing elective surgery or with trauma, and nursing home residents were excluded. Of 6795 patients screened, a total of 684 (544 in the nonintervention group and 140 in the intervention group) were included. Data were collected from April 14, 2014, to March 28, 2017, and analyzed from November 16, 2018, through May 30, 2019. Interventions Integration of a geriatric assessment team, optimization of evidence-based elder-friendly practices, promotion of patient-oriented rehabilitation, and early discharge planning. Main Outcomes and Measures Proportion of participants experiencing a major complication or death (composite) in the hospital, Comprehensive Complication Index, length of hospital stay, and proportion of participants who required an alternative level of care on discharge. Covariate-adjusted, within-site change scores were computed, and the overall between-site, preintervention-postintervention difference-in-differences (DID) were analyzed. Results A total of 684 patients were included in the analysis (mean [SD] age, 76.0 [7.6] years; 327 women [47.8%] and 357 men [52.2%]), of whom 139 (20.3%) were frail. At the intervention site, in-hospital major complications or death decreased by 19% (51 of 153 [33.3%] vs 19 of 140 [13.6%]; P < .001; DID P = .06), and mean (SE) Comprehensive Complication Index decreased by 12.2 (2.5) points (P < .001; DID P < .001). Median length of stay decreased by 3 days (10 [interquartile range (IQR), 6-17] days to 7 [IQR, 5-14] days; P = .001; DID P = .61), and fewer patients required an alternative level of care at discharge (61 of 153 [39.9%] vs 29 of 140 [20.7%]; P < .001; DID P = .11). Conclusions and Relevance To our knowledge, this is the first study to examine clinical outcomes associated with a novel elder-friendly surgical care delivery redesign. The findings suggest the clinical effectiveness of such an approach by reducing major complications or death, decreasing hospital stays, and returning patients to their home residence. Trial Registration ClinicalTrials.gov Identifier: NCT02233153.
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Affiliation(s)
- Rachel G Khadaroo
- Department of Surgery, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada.,Department of Critical Care Medicine, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Lindsey M Warkentin
- Department of Surgery, Walter C. Mackenzie Health Sciences Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian S Wagg
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Raj S Padwal
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Fiona Clement
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Xiaoming Wang
- Aberhart Centre, Research Facilitation, Alberta Health Services, Edmonton, Alberta, Canada
| | - William D Buie
- Department of Surgery, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jayna Holroyd-Leduc
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
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Sánchez Acedo P, Eguaras Córdoba I, Zazpe Ripa C, Herrera Cabezón J, Tarifa Castilla A. Prospective Study of Factors Associated With Postoperative Delirium After Urgent Abdominal Surgery. Cir Esp 2020; 98:450-455. [PMID: 32248983 DOI: 10.1016/j.ciresp.2020.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 01/18/2020] [Accepted: 01/22/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Delirium is a frequent complication in elderly patients after urgent abdominal surgery. METHODS Prospective study of consecutive patients aged ≥65years who had undergone urgent abdominal surgery from 2017-2019. The following variables were recorded: age, sex, ASA, physiological state, cognitive impairment, frailty (FRAIL Scale), functional dependence (Barthel Scale), quality of life (Euroqol-5D-VAS), nutritional status (MNA-SF), preoperative diagnosis, type of surgery (BUPA Classification), approach and diagnosis of postoperative delirium (Confusion Assessment Method). Univariate and multivariate analyses were performed to analyze the correlation of these variables with delirium. RESULTS The study includes 446 patients with a median age of 78years, 63.6% were ASA ≥III and 8% had prior cognitive impairment. 13.2% were frail and 5.4% of the patients had a severe or total degree of dependence. 13.6% developed delirium in the postoperative period. In the univariate analysis, all the variables were statistically significant except for sex, type of surgery (BUPA) and duration. In the multivariate analysis the associated factors were: age (P<.001; OR: 1,08; 95%CI: 1,038-1,139), ASA (P=.026; OR: 3.15; 95%CI: 1.149-8.668), physiological state (P<.001; OR: 5.8; 95%CI: 2.176-15.457), diagnosis (P=.006) and cognitive impairment (P<.001; OR: 5.8; 95%CI: 2.391-14.069). CONCLUSION The factors associated with delirium are age, ASA, physiological state in the emergency room, preoperative diagnosis and prior cognitive impairment.
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Affiliation(s)
| | | | - Cruz Zazpe Ripa
- Cirugía General, Complejo Hospitalario de Navarra, Navarra, España
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Risk factors for postoperative delirium after colorectal surgery: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:433-444. [PMID: 31897646 DOI: 10.1007/s00384-019-03498-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2019] [Indexed: 02/04/2023]
Abstract
PURPOSE Postoperative delirium is common after any type of surgery and can lead to serious outcomes; thus, its prevention is important. Early assessment can help identify patients at higher risk of postoperative delirium. However, the risk factors for postoperative delirium in patients who underwent colorectal surgery are unclear. This meta-analysis aimed to identify the risk factors for postoperative delirium after colorectal cancer surgery. METHODS We selected all articles related to postoperative delirium after colorectal surgery published up to March 2019. Studies using any method for diagnosing delirium were eligible. Ovid-Embase, Ovid-Medline, and the Cochrane library were searched. Two reviewers independently conducted quality assessment and data collection. The risk factors identified in the studies were recorded, and a meta-analysis was conducted. RESULTS Of the 1216 studies initially screened, 1197 were reviewed by two independent reviewers. Finally, 14 articles were identified to be relevant for this review. In total, 11 of the 14 studies reported the risk factors for postoperative delirium. The incidence of postoperative delirium ranged from 8% to 54%. A total of 19 risk factors were identified, and we classified them into two categories as patient-related and treatment-related risk factors. CONCLUSION Postoperative delirium is highly common in those undergoing colorectal surgery including cancer, with advanced old age, history of preoperative delirium and preoperative serum albumin level which are risk factors for POD. Larger multi-institutional randomized studies to address this issue are warranted in the future.
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Prevalence and risk factors for postoperative delirium in patients with colorectal carcinoma: a systematic review and meta-analysis. Int J Colorectal Dis 2020; 35:547-557. [PMID: 31955218 DOI: 10.1007/s00384-020-03505-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2020] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Postoperative delirium (POD) is a common, but severe complication in elderly patients undergoing surgery for colorectal cancer, but the prevalence and potential risk factors for POD were not well established. Therefore, a meta-analysis was preformed to clarify the prevalence and risk factors of POD in patients undergoing surgery for colorectal cancer. METHODS PubMed, Embase, and the Cochrane Library were systematically searched on August 2019. Studies were included if they reported the prevalence and risk factors of POD in patients undergoing colorectal cancer surgery. The guidelines for critically appraising studies of prevalence or incidence of a health problem were used to assess the quality of included studies. Pooled odds ratios (ORs) for individual risk factors were estimated using the Mantel-Haenszel methods in random effect model. Sensitive analyses based on different inclusion criteria were conducted to explore whether the current meta-analysis was enough credible and robust. RESULTS Seventeen studies totaling 4472 patients undergoing colorectal cancer surgery were included. The pooled prevalence of POD is 14% (95% CI = 12-17%). Twelve significant risk factors were identified in pooled analysis including older age (OR = 1.10), sex (OR = 1.87), history of psychiatric disease (OR = 6.47), comorbidities (OR = 2.17), prognostic nutritional index (OR = 1.12), physical status (OR = 1.27), American Society of Anesthesiologists Score (ASA Scores) (OR = 1.65), history of alcohol abuse (OR = 2.23), postoperative pain management (OR = 1.91), perioperative blood transfusion (OR = 2.37), cognitive status (OR = 1.91), and lower serum level of albumin (OR = 0.58). CONCLUSIONS POD is a frequent complication in patients undergoing surgery with colorectal cancer. Several risk factors including history of psychiatric disease, transfusion, comorbidities, male gender, and old age were significant predictors for POD.
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Chang MT, Jitaroon K, Nguyen T, Yan CH, Overdevest JB, Nayak JV, Hwang PH, Patel ZM. Hemodynamic changes in patients undergoing office-based sinus procedures under local anesthesia. Int Forum Allergy Rhinol 2019; 10:114-120. [PMID: 31899857 DOI: 10.1002/alr.22460] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 08/26/2019] [Accepted: 09/13/2019] [Indexed: 11/12/2022]
Abstract
BACKGROUND The objective of this study is to characterize changes in hemodynamics, pain, and anxiety during office-based endoscopic sinus procedures performed under local anesthesia. METHODS We conducted a prospective study of adults undergoing in-office endoscopic sinus procedures under local anesthesia. Patients with American Society of Anesthesiologists (ASA) Physical Status Classification System class 1 or 2 were included. Anesthesia was administered by topical 4% lidocaine/oxymetazoline and submucosal injection of 1% lidocaine/1:200,000 epinephrine. Vital signs and pain were measured at baseline, postinjection, and 5-minute intervals throughout the procedure. Anxiety levels were scored using the State-Trait Anxiety Inventory (STAI). Univariate and multivariate regression analyses were performed to identify factors significantly associated with changes in each hemodynamic metric. RESULTS Twenty-five patients were studied. This cohort was 52% male, mean age of 57.8 ± 14.4 years, and Charlson Comorbidity Index (CCI) median of 2. Mean procedure duration was 25.0 ± 10.3 minutes. Mean maximal increase in systolic blood pressure (SBP) was 24.6 ± 17.8 mmHg from baseline. Mean maximal heart rate increase was 22.8 ± 10.8 beats per minute (bpm) from baseline. In multivariate regression analysis, when accounting for patient age, cardiac comorbidity, CCI, and ASA, older age was significantly associated with an increase of >20 mmHg in SBP (p = 0.043). Mean pain score during procedures was 1.5 ± 1.3 with a mean maximum of 4.0 ± 2.6. STAI anxiety scores did not change significantly from preprocedure to postprocedure (32.8 ± 11.6 to 31.0 ± 12.6, p = 0.46). No medical complications occurred. CONCLUSION Although patients appear to tolerate office procedures well, providers should recognize the potential for significant fluctuations in blood pressure during the procedure, especially in older patients.
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Affiliation(s)
- Michael T Chang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Kawinyarat Jitaroon
- Department of Otolaryngology, Navamindradhiraj University, Bangkok, Thailand
| | - Teresa Nguyen
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Carol H Yan
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Jonathan B Overdevest
- Department of Otolaryngology-Head & Neck Surgery, Columbia University Medical Center, New York, NY
| | - Jayakar V Nayak
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Peter H Hwang
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
| | - Zara M Patel
- Department of Otolaryngology-Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA
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Dementia in elderly patients undergoing early cholecystectomy for acute cholecystitis: a retrospective observational study. BMC Surg 2019; 19:71. [PMID: 31262275 PMCID: PMC6604413 DOI: 10.1186/s12893-019-0548-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 06/26/2019] [Indexed: 12/24/2022] Open
Abstract
Background Dementia often adversely affects postoperative outcomes in surgical patients. This study evaluated postoperative outcomes among elderly patients with and without dementia undergoing early cholecystectomy for acute cholecystitis (AC). Methods A total of 182 patients over 85 years of age who were diagnosed with AC and treated from January 2005 to March 2018 were reviewed retrospectively; 59 patients who underwent early cholecystectomy were enrolled. The complication rates, length of postoperative hospital stay, and rates of routine discharge (i.e., returning to their preoperative living location) were compared between two groups of patients with and without dementia. Results The overall complication rate after early cholecystectomy for AC in 59 patients was 11.9%, and there was no mortality in this series. The median postoperative hospital stay was 9.0 days, and the routine discharge rate was 89.8%. Of the 59 patients, 22 patients (37.3%) had a history of dementia. Complication rates were comparable between the groups, despite the rate of delirium development being significantly higher in the dementia group. The median length of postoperative hospital stay and routine discharge rates did not significantly differ between groups. Conclusions Early cholecystectomy for patients with AC over 85 years of age was performed safely, and elderly patients with dementia had similar postoperative outcomes as compared with patients without dementia.
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Champagne PO, Brunette-Clement T, Bojanowski MW, Moumdjian R, Fournier-Gosselin MP, Bouthillier A, Shedid D. Safety of performing craniotomy in the elderly: The utility of co-morbidity indices. INTERDISCIPLINARY NEUROSURGERY 2018. [DOI: 10.1016/j.inat.2018.07.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Miller D, Lewis SR, Pritchard MW, Schofield‐Robinson OJ, Shelton CL, Alderson P, Smith AF. Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly people undergoing non-cardiac surgery. Cochrane Database Syst Rev 2018; 8:CD012317. [PMID: 30129968 PMCID: PMC6513211 DOI: 10.1002/14651858.cd012317.pub2] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The use of anaesthetics in the elderly surgical population (more than 60 years of age) is increasing. Postoperative delirium, an acute condition characterized by reduced awareness of the environment and a disturbance in attention, typically occurs between 24 and 72 hours after surgery and can affect up to 60% of elderly surgical patients. Postoperative cognitive dysfunction (POCD) is a new-onset of cognitive impairment which may persist for weeks or months after surgery.Traditionally, surgical anaesthesia has been maintained with inhalational agents. End-tidal concentrations require adjustment to balance the risks of accidental awareness and excessive dosing in elderly people. As an alternative, propofol-based total intravenous anaesthesia (TIVA) offers a more rapid recovery and reduces postoperative nausea and vomiting. Using TIVA with a target controlled infusion (TCI) allows plasma and effect-site concentrations to be calculated using an algorithm based on age, gender, weight and height of the patient.TIVA is a viable alternative to inhalational maintenance agents for surgical anaesthesia in elderly people. However, in terms of postoperative cognitive outcomes, the optimal technique is unknown. OBJECTIVES To compare maintenance of general anaesthesia for elderly people undergoing non-cardiac surgery using propofol-based TIVA or inhalational anaesthesia on postoperative cognitive function, mortality, risk of hypotension, length of stay in the postanaesthesia care unit (PACU), and hospital stay. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 11), MEDLINE (1946 to November 2017), Embase (1974 to November 2017), PsycINFO (1887 to November 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA We included randomized controlled trials (RCTs) with participants over 60 years of age scheduled for non-cardiac surgery under general anaesthesia. We planned to also include quasi-randomized trials. We compared maintenance of anaesthesia with propofol-based TIVA versus inhalational maintenance of anaesthesia. DATA COLLECTION AND ANALYSIS Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias, and synthesized findings. MAIN RESULTS We included 28 RCTs with 4507 randomized participants undergoing different types of surgery (predominantly cardiovascular, laparoscopic, abdominal, orthopaedic and ophthalmic procedures). We found no quasi-randomized trials. Four studies are awaiting classification because we had insufficient information to assess eligibility.All studies compared maintenance with propofol-based TIVA versus inhalational maintenance of anaesthesia. Six studies were multi-arm and included additional TIVA groups, additional inhalational maintenance or both. Inhalational maintenance agents included sevoflurane (19 studies), isoflurane (eight studies), and desflurane (three studies), and was not specified in one study (reported as an abstract). Some studies also reported use of epidural analgesia/anaesthesia, fentanyl and remifentanil.We found insufficient reporting of randomization methods in many studies and all studies were at high risk of performance bias because it was not feasible to blind anaesthetists to study groups. Thirteen studies described blinding of outcome assessors. Three studies had a high of risk of attrition bias, and we noted differences in the use of analgesics between groups in six studies, and differences in baseline characteristics in five studies. Few studies reported clinical trials registration, which prevented assessment of risk of selective reporting bias.We found no evidence of a difference in incidences of postoperative delirium according to type of anaesthetic maintenance agents (odds ratio (OR) 0.59, 95% confidence interval (CI) 0.15 to 2.26; 321 participants; five studies; very low-certainty evidence); we noted during sensitivity analysis that using different time points in one study may influence direction of this result. Thirteen studies (3215 participants) reported POCD, and of these, six studies reported data that could not be pooled; we noted no difference in scores of POCD in four of these and in one study, data were at a time point incomparable to other studies. We excluded one large study from meta-analysis because study investigators had used non-standard anaesthetic management and this study was not methodologically comparable to other studies. We combined data for seven studies and found low-certainty evidence that TIVA may reduce POCD (OR 0.52, 95% CI 0.31 to 0.87; 869 participants).We found no evidence of a difference in mortality at 30 days (OR 1.21, 95% CI 0.33 to 4.45; 271 participants; three studies; very low-certainty evidence). Twelve studies reported intraoperative hypotension. We did not perform meta-analysis for 11 studies for this outcome. We noted visual inconsistencies in these data, which may be explained by possible variation in clinical management and medication used to manage hypotension in each study (downgraded to low-certainty evidence); one study reported data in a format that could not be combined and we noted little or no difference between groups in intraoperative hypotension for this study. Eight studies reported length of stay in the PACU, and we did not perform meta-analysis for seven studies. We noted visual inconsistencies in these data, which may be explained by possible differences in definition of time points for this outcome (downgraded to very low-certainty evidence); data were unclearly reported in one study. We found no evidence of a difference in length of hospital stay according to type of anaesthetic maintenance agent (mean difference (MD) 0 days, 95% CI -1.32 to 1.32; 175 participants; four studies; very low-certainty evidence).We used the GRADE approach to downgrade the certainty of the evidence for each outcome. Reasons for downgrading included: study limitations, because some included studies insufficiently reported randomization methods, had high attrition bias, or high risk of selective reporting bias; imprecision, because we found few studies; inconsistency, because we noted heterogeneity across studies. AUTHORS' CONCLUSIONS We are uncertain whether maintenance with propofol-based TIVA or with inhalational agents affect incidences of postoperative delirium, mortality, or length of hospital stay because certainty of the evidence was very low. We found low-certainty evidence that maintenance with propofol-based TIVA may reduce POCD. We were unable to perform meta-analysis for intraoperative hypotension or length of stay in the PACU because of heterogeneity between studies. We identified 11 ongoing studies from clinical trials register searches; inclusion of these studies in future review updates may provide more certainty for the review outcomes.
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Affiliation(s)
- David Miller
- North Cumbria University HospitalsAcademic UnitCumberland InfirmaryNewtown RoadCarlisleUKCA2 7HY
| | - Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Oliver J Schofield‐Robinson
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | | | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaAshton RoadLancasterLancashireUKLA1 4RP
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Noh G, Kwon I, Lee M, Ahn SH, Kim JL. Factor Analysis of Delirium in Elderly, Using the Korean Version of Delirium Rating Scale-Revised-98. Psychiatry Investig 2018; 15:484-489. [PMID: 29614850 PMCID: PMC5975997 DOI: 10.30773/pi.2017.10.06] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/06/2017] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE This study aimed to identify the core symptoms of delirium, particularly in elderly people associated with major risk factors, using the Korean version of the Delirium Rating Scale-Revised-98. METHODS The study sample consisted of 200 patients (mean age: 72.7±3.9 years, male: 68.5%) who had been diagnosed with delirium. Exploratory factor analysis was used to investigate the factor structure, and confirmatory factor analysis was used to evaluate the goodness of fit of the results. RESULTS The results demonstrated three core domains of delirium in the elderly patients: 1) the cognitive domain (e.g., language, thought process, orientation, attention, long-term memory, and visuospatial ability); 2) the circadian domain (e.g., sleep-wake cycle and motor behavior); and 3) the short-term memory domain (short-term memory). These results were confirmed by confirmatory factor analysis. CONCLUSION The findings of this study suggest a theoretical domain structure for delirium in elderly patients.
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Affiliation(s)
- Gahye Noh
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Insun Kwon
- Department of Statistics, Chungnam National University Hospital, Clinical Trials Center, Daejeon, Republic of Korea
| | - Miji Lee
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - So Hyun Ahn
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Jeong Lan Kim
- Department of Psychiatry, Chungnam National University Hospital, Daejeon, Republic of Korea.,Department of Psychiatry, School of Medicine, Chungnam National University, Daejeon, Republic of Korea
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23
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Watt J, Tricco AC, Talbot-Hamon C, Pham B, Rios P, Grudniewicz A, Wong C, Sinclair D, Straus SE. Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis. J Gen Intern Med 2018; 33:500-509. [PMID: 29374358 PMCID: PMC5880753 DOI: 10.1007/s11606-017-4204-x] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Revised: 09/22/2017] [Accepted: 09/29/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery. METHODS Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates. RESULTS Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3-23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2-17.9), frailty (OR 4.1, 95% CI 1.4-11.7), cognitive impairment (OR 2.7, 95% CI 1.9-3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6-2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3-2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4-3.6) and smoking status (OR 1.8 95% CI 1.3-2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52-0.91). DISCUSSION Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.
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Affiliation(s)
- Jennifer Watt
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada.,Institute for Health Policy Management & Evaluation, University of Toronto, 4th Floor, 155 College Street, Toronto, Ontario, M5T 3M6, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Epidemiology Division, Dalla Lana School of Public Health, University of Toronto, Health Sciences Building, 155 College Street, 6th floor, Toronto, Ontario, M5T 3M7, Canada
| | - Catherine Talbot-Hamon
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada
| | - Ba' Pham
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.,Toronto Health Economics and Technology Assessment Collaborative, Faculty of Pharmacy and Institute of Health Policy Management Evaluation, University of Toronto, 144 College Street, Toronto, Ontario, M5S 3M2, Canada
| | - Patricia Rios
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, 55 Laurier Avenue East, Ottawa, Ontario, K1N 6N5, Canada
| | - Camilla Wong
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Douglas Sinclair
- Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada
| | - Sharon E Straus
- Department of Geriatric Medicine, University of Toronto, 27 King's College Circle, Toronto, Ontario, M5S 1A1, Canada. .,Knowledge Translation Program, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 209 Victoria Street, East Building, Room 716, Toronto, Ontario, M5B 1W8, Canada.
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Monacelli F, Signori A, Prefumo M, Giannotti C, Nencioni A, Romairone E, Scabini S, Odetti P. Delirium, Frailty, and Fast-Track Surgery in Oncogeriatrics: Is There a Link? Dement Geriatr Cogn Dis Extra 2018. [PMID: 29515621 PMCID: PMC5836168 DOI: 10.1159/000486519] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background/Aims Postoperative delirium (POD) is more frequent in elderly patients undergoing major cancer surgery. The interplay between individual clinical vulnerability and a series of perioperative factors seems to play a relevant role. Surgery is the first-line treatment option for cancer, and fast-track surgery (FTS) has been documented to decrease postoperative complications. The study sought to assess, after comprehensive geriatric assessment (CGA) and frailty stratification (Rockwood 40 items index), which perioperative parameters were predictive of POD development in elderly patients undergoing FTS for colorectal cancer. Methods A total of 107 consecutive subjects admitted for elective colorectal FTS were enrolled. All patients underwent CGA, frailly stratification, Timed up & go (TUG) test, 4AT test for delirium screening, anesthesiologists physical status classification, and Dindo-Clavien classification. Results The incidence of POD was 12.3%. Patients’ prevalent clinical phenotype was pre-frail. The multivariate analysis indicated physical performance (TUG in seconds) as the most significant predictor of POD for each second of increase. Conclusions Only few procedure-specific studies have examined the impact of FTS for colorectal cancer on POD. This is the first study to investigate the risk factors for POD, in a vulnerable octogenarian oncogeriatric population submitted to FTS surgery and frailty stratification.
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Affiliation(s)
- Fiammetta Monacelli
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Alessio Signori
- bDISSAL, Department of Health Science, University of Genoa, Genoa, Italy
| | - Matteo Prefumo
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Chiara Giannotti
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Alessio Nencioni
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy.,dI.R.C.C.S. per l'Oncologia, Hospital Policlinic San Martino, Genoa, Italy
| | - Emanuele Romairone
- cOncological Surgery and Implantable Systems, Hospital Policlinic San Martino, Genoa, Italy
| | - Stefano Scabini
- cOncological Surgery and Implantable Systems, Hospital Policlinic San Martino, Genoa, Italy
| | - Patrizio Odetti
- aHospital Policlinic San Martino, Section of Geriatric Medicine, Department of Internal Medicine and Medical Specialties (DIMI), University of Genoa, Genoa, Italy
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Fagard K, Casaer J, Wolthuis A, Flamaing J, Milisen K, Lobelle JP, Wildiers H, Kenis C. Postoperative complications in individuals aged 70 and over undergoing elective surgery for colorectal cancer. Colorectal Dis 2017; 19:O329-O338. [PMID: 28733982 DOI: 10.1111/codi.13821] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2017] [Accepted: 07/17/2017] [Indexed: 02/08/2023]
Abstract
AIM This study aims to describe the nature, incidence, severity and outcomes of in-hospital postoperative complications (POCs) in older patients undergoing elective surgery for colorectal cancer. METHOD Patients ≥ 70 years old were identified from a prospectively collected database (2009-2015) focusing on the implementation of geriatric screening and assessment in patients with cancer. Medical and surgical POCs were retrieved retrospectively from the medical records, and the severity of the POCs was graded by the Clavien-Dindo (CD) grading system. The following outcomes were analysed comparing patients with and without CD ≥ 2 and CD ≥ 3 POCs: length of stay (LOS), transfer to the intensive care unit, 30-day readmission rates, 30-day and 1-year mortality. RESULTS In the 190 patients included, medical POCs (40.5%) were more frequent than surgical POCs (17.9%), and 37.9% experienced CD ≥ 2 POCs. The most common medical POCs were infections (26.8%), transient confusion or altered mental function (12.1%), cardiac arrhythmia (4.7%), and ileus/gastroparesis/prolonged recovery of transit (4.7%). The most common surgical POCs were surgical site infections (12.1%), wound dehiscence/bleeding (4.7%), anastomotic leak (3.7%) and surgical site bleeding (3.7%). The reoperation rate was 7.9%. CD ≥ 2 POCs led to 11 intensive care unit admissions and increased median postoperative LOS by 114% (P < 0.0001 for both), but did not significantly alter 30-day readmission and 30-day and 1-year mortality rates. CD ≥ 3 POCs increased LOS by 162% (P < 0.0001) and showed an increased 1-year mortality (P = 0.07). CONCLUSION This study shows that in-hospital medical and surgical complications after surgery for colorectal cancer in patients ≥ 70 years old are frequent and that complications lead to less favourable outcomes.
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Affiliation(s)
- K Fagard
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
| | - J Casaer
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - A Wolthuis
- Department of Abdominal Surgery, University Hospitals Leuven, Leuven, Belgium
| | - J Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Clinical and Experimental Medicine, KU Leuven, Leuven, Belgium
| | - K Milisen
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Public Health and Primary Care, Academic Centre for Nursing and Midwifery, KU Leuven, Leuven, Belgium
| | | | - H Wildiers
- Department of Oncology, KU Leuven, Leuven, Belgium.,Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
| | - C Kenis
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of General Medical Oncology, University Hospitals Leuven, Leuven, Belgium
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Aranake-Chrisinger A, Avidan M. Postoperative delirium portends descent to dementia. Br J Anaesth 2017; 119:285-288. [DOI: 10.1093/bja/aex126] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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A Systematic Review and Meta-analysis Examining the Impact of Incident Postoperative Delirium on Mortality. Anesthesiology 2017; 127:78-88. [DOI: 10.1097/aln.0000000000001660] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Abstract
Background
Delirium is an acute and reversible geriatric syndrome that represents a decompensation of cerebral function. Delirium is associated with adverse postoperative outcomes, but controversy exists regarding whether delirium is an independent predictor of mortality. Thus, we assessed the association between incident postoperative delirium and mortality in adult noncardiac surgery patients.
Methods
A systematic search was conducted using Cochrane, MEDLINE/PubMed, Cumulative Index to Nursing and Allied Health Literature, and Embase. Screening and data extraction were conducted by two independent reviewers. Pooled-effect estimates calculated with a random-effects model were expressed as odds ratios with 95% CIs. Risk of bias was assessed using the Cochrane Risk of Bias Tool for Non-Randomized Studies.
Results
A total of 34 of 4,968 screened citations met inclusion criteria. Risk of bias ranged from moderate to critical. Pooled analysis of unadjusted event rates (5,545 patients) suggested that delirium was associated with a four-fold increase in the odds of death (odds ratio = 4.12 [95% CI, 3.29 to 5.17]; I2 = 24.9%). A formal pooled analysis of adjusted outcomes was not possible due to heterogeneity of effect measures reported. However, in studies that controlled for prespecified confounders, none found a statistically significant association between incident postoperative delirium and mortality (two studies in hip fractures; n = 729) after an average follow-up of 21 months. Overall, as study risk of bias decreased, the association between delirium and mortality decreased.
Conclusions
Few high-quality studies are available to estimate the impact of incident postoperative delirium on mortality. Studies that controlled for prespecified confounders did not demonstrate significant independent associations of delirium with mortality.
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Venara A, Barbieux J, Mucci S, Talbot MF, Lermite E, Hamy A. Short-Term Outcomes of Colorectal Resection for Cancer in Elderly in the Era of Enhanced Recovery. Scand J Surg 2017; 107:31-37. [PMID: 28464708 DOI: 10.1177/1457496917706010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIMS Early rehabilitation protocols should be assessed in elderly. We aimed to study the outcomes of colorectal surgery and the observance of the modalities of an early rehabilitation protocol in patients over 80 years. MATERIAL AND METHODS All consecutive patients who underwent surgery for colorectal cancer in our center over a 19-month period were included. All of these patients were managed using the same early rehabilitation protocol. Patients older than 80 were compared to younger patients. RESULTS A total of 173 patients were included and 36 were ≥80 years (20.8%). Patients aged ≥80 years had a significantly higher ASA score and were operated on in emergency. In the peroperative period, patients aged ≥80 years were more likely to undergo laparotomy than patients <80 years in univariate analysis (p = 0.048), but in multivariate analysis, the choice for a laparoscopy was influenced by ASA score ≤2 (odds ratio = 3.55, 95% confidence interval = 1.67-7.58) and emergency surgery (odds ratio = 0.18, 95% confidence interval = 0.06-0.50). In the postoperative period, peristalsis stimulation and vascular catheter ablation were significantly better followed in Group 1 (p = 0.012 and 0.031). However, in multivariate analysis, age was not significantly associated with these parameters. Peristalsis stimulation was influenced by ASA score ≥2 (odds ratio = 4.27, 95% confidence interval = 1.18-15.37) and vascular catheter ablation was also influenced by ASA score ≤2 (odds ratio = 2.63, 95% confidence interval = 1.33-5.21). Emergency surgery had a strong trend to influence these parameters (p = 0.08). CONCLUSION Although age or comorbidities may affect observance for certain modalities such as chewing gum use and vascular catheter ablation, an early rehabilitation protocol can be used after colorectal cancer surgery in patients ≥80 years old, where it would improve functional results and postoperative outcomes.
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Affiliation(s)
- A Venara
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France.,3 UMR INSERM 1235, TENS, the enteric nervous system in gut and brain disorder, University of Nantes, Nantes, France
| | - J Barbieux
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - S Mucci
- 1 L'UNAM and University of Angers, Angers, France
| | - M F Talbot
- 4 Department of Anesthesia and Intensive Care, CHU Angers, Angers, France
| | - E Lermite
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
| | - A Hamy
- 1 L'UNAM and University of Angers, Angers, France.,2 Department of Visceral Surgery, CHU Angers, Angers, France
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30
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Raats JW, Steunenberg SL, de Lange DC, van der Laan L. Risk factors of post-operative delirium after elective vascular surgery in the elderly: A systematic review. Int J Surg 2016; 35:1-6. [PMID: 27613124 DOI: 10.1016/j.ijsu.2016.09.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 08/31/2016] [Accepted: 09/04/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Postoperative delirium is a common and serious adverse event in the elderly patient and is associated with significant morbidity and mortality. It is of great importance to identify patients at risk for delirium, in order to focus preventive strategies. The aim of this article is to systematically review current available literature on pre-operative risk factors for delirium after vascular surgery. METHODS A systematic literature search was conducted using PubMed and EMBASE, using the MeSH terms and key words "delirium", "surgery" and "risk factor". Studies were retained for review after meeting strict inclusion criteria that included only prospective studies evaluating risk factors for delirium in patients who had elective vascular surgery. Diagnosis of delirium needed to be confirmed using the Diagnostic and Statistical Manual of Mental Disorders (DSM) or ICD-10. RESULTS Fifteen articles were selected for inclusion, incidence of delirium across the studies ranged from 5% to 39%. Many factors have been associated with increased risk of delirium, including age, cognitive impairment, comorbidity, depression, smoking, alcohol, visual and hearing impairment, ASA-score, biochemical abnormalities, operative strategies and blood loss. CONCLUSIONS Delirium is a common complication after elective vascular surgery in elderly. The highest delirium incidence was observed after open aortic surgery as well as after surgery for critical limb ischemia. A picture starts to form of which predisposing factors lead to increased risk of delirium. The leading risk factors consistently identified in this systematic review were advanced age and cognitive impairment. Multi-disciplinary specialist-led interventions in the preoperative phase could decrease incidence and severity of delirium and should be focused on identified high-risk patients.
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Affiliation(s)
- J W Raats
- Department of Surgery, Amphia Hospital, Breda, The Netherlands.
| | - S L Steunenberg
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - D C de Lange
- Department of Geriatric Medicine, Amphia Hospital, Breda, The Netherlands
| | - L van der Laan
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
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Miller ID, Shelton CL, Lewis SR, Alderson P, Smith AF. Intravenous versus inhalational maintenance of anaesthesia for postoperative cognitive outcomes in elderly surgical patients. Cochrane Database Syst Rev 2016. [DOI: 10.1002/14651858.cd012317] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- I. David Miller
- North Cumbria University Hospitals; Academic Unit; Cumberland Infirmary Newtown Road Carlisle UK CA2 7HY
| | - Cliff L Shelton
- Lancaster University; Lancaster Medical School; Lancaster UK
| | - Sharon R Lewis
- Royal Lancaster Infirmary; Patient Safety Research Department; Pointer Court 1, Ashton Road Lancaster UK LA1 1RP
| | - Phil Alderson
- National Institute for Health and Care Excellence; Level 1A, City Tower, Piccadilly Plaza Manchester UK M1 4BD
| | - Andrew F Smith
- Royal Lancaster Infirmary; Department of Anaesthesia; Ashton Road Lancaster Lancashire UK LA1 4RP
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Xue FS, Li RP, Liu GP. Association of intraoperative arterial blood pressure lability with postoperative adverse outcome: no one size fits all. Br J Anaesth 2016; 117:258-9. [PMID: 27440638 DOI: 10.1093/bja/aew199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- F S Xue
- Beijing, People's Republic of China
| | - R P Li
- Beijing, People's Republic of China
| | - G P Liu
- Beijing, People's Republic of China
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Jeong YM, Lee E, Kim KI, Chung JE, In Park H, Lee BK, Gwak HS. Association of pre-operative medication use with post-operative delirium in surgical oncology patients receiving comprehensive geriatric assessment. BMC Geriatr 2016; 16:134. [PMID: 27388509 PMCID: PMC4937600 DOI: 10.1186/s12877-016-0311-5] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 06/22/2016] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Older patients undergoing surgery tend to have a higher frequency of delirium. Delirium is strongly associated with poor surgical outcomes. This study evaluated the association between pre-operative medication use and post-operative delirium (POD) in surgical oncology patients receiving comprehensive geriatric assessment (CGA). METHODS A total of 475 patients who were scheduled for cancer surgery and received CGA from January 2014 to June 2015 were included. Pre-operative medication review through CGA was conducted on polypharmacy (≥5 medications), delirium-inducing medications (DIMs), fall-inducing medications (FIMs), and potentially inappropriate medications (PIMs). POD was confirmed by psychiatric consultation, and DSM-V criteria were used for diagnosing delirium. The model fit of the prediction model was assessed by computing the Hosmer-Lemeshow goodness-of-fit test. Effect size was measured using the Nagelkerke R(2). Discrimination of the model was assessed by an analysis of the area under receiver operating curve (AUROC). RESULTS Two models were constructed for multivariate analysis based on univariate analysis; model I included dementia and DIM in addition to age and sex, and model II included PIM instead of DIM of model I. Every one year increase of age increased the risk of POD by about 1.1-fold. DIM was a significant factor for POD after adjusting for confounders (AOR 12.78, 95 % CI 2.83-57.74). PIM was also a significant factor for POD (AOR 5.53, 95 % CI 2.03-15.05). The Hosmer-Lemeshow test results revealed good fits for both models (χ(2) = 3.842, p = 0.871 for model I and χ(2) = 8.130, p = 0.421 for model II). The Nagelkerke R(2) effect size and AUROC for model I was 0.215 and 0.833, respectively. Model II had the Nagelkerke R(2)effect size of 0.174 and AUROC of 0.819. CONCLUSIONS These results suggest that pharmacists' comprehensive review for pre-operative medication use is critical for the post-operative outcomes like delirium in older patients.
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Affiliation(s)
- Young Mi Jeong
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.,Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Kwang-Il Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Jee Eun Chung
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Hae In Park
- Department of Pharmacy, Seoul National University Bundang Hospital, Seongnam, 13620, Republic of Korea
| | - Byung Koo Lee
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy & Division of Life and Pharmaceutical Sciences, Ewha Womans University, Seoul, 03760, Republic of Korea.
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Pearce L, Bunni J, McCarthy K, Hewitt J. Surgery in the older person: Training needs for the provision of multidisciplinary care. Ann R Coll Surg Engl 2016; 98:367-70. [PMID: 27269239 DOI: 10.1308/rcsann.2016.0180] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction Many older surgical patients are exposed to high risks of morbidity and mortality when undergoing both elective and emergency surgery. Methods We provide an overview of perioperative care teams and the educational opportunities available to surgeons who undertake surgery in the older person. Findings The number of older people undergoing surgery is increasing at a rate faster than the proportion of older people in the overall population. Management of the older surgical patient throughout the surgical pathway forms part of the Specialty Training Curriculum for Geriatric Medicine. While 'surgery in childhood' continues to form part of the general surgical higher training syllabus, surgery in the later years of life does not. There are limited postgraduate courses and training opportunities currently available to surgeons in this field. There is clear societal need to address perioperative care for older surgical patients, which has proved successful in some centers. Moreover, surgical trainees support the inclusion of geriatric medicine issues into their training. Conclusions The ageing population requires a multidisciplinary perioperative approach, with dedicated and appropriately trained clinicians and allied health care professionals to improve outcomes.
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Affiliation(s)
- L Pearce
- Manchester Royal Infirmary , Manchester , UK
| | - J Bunni
- Cheltenham General Hospital , Cheltenham , UK
| | | | - J Hewitt
- Cardiff University , Cardiff , UK
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Breugom AJ, van Dongen DT, Bastiaannet E, Dekker FW, van der Geest LGM, Liefers GJ, Marinelli AWKS, Mesker WE, Portielje JEA, Steup WH, Tseng LNL, van de Velde CJH, Dekker JWT. Association Between the Most Frequent Complications After Surgery for Stage I–III Colon Cancer and Short-Term Survival, Long-Term Survival, and Recurrences. Ann Surg Oncol 2016; 23:2858-65. [DOI: 10.1245/s10434-016-5226-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Indexed: 01/26/2023]
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Early Postoperative Withholding Angiotensin Receptor Blockers and 30-day Mortality after Noncardiac Surgery. Anesthesiology 2016; 124:512-3. [PMID: 26785435 DOI: 10.1097/aln.0000000000000964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Raats JW, van Eijsden WA, Crolla RMPH, Steyerberg EW, van der Laan L. Risk Factors and Outcomes for Postoperative Delirium after Major Surgery in Elderly Patients. PLoS One 2015; 10:e0136071. [PMID: 26291459 PMCID: PMC4546338 DOI: 10.1371/journal.pone.0136071] [Citation(s) in RCA: 177] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
Background Early identification of patients at risk for delirium is important, since adequate well timed interventions could prevent occurrence of delirium and related detrimental outcomes. The aim of this study is to evaluate prognostic factors for delirium, including factors describing frailty, in elderly patients undergoing major surgery. Methods We included patients of 65 years and older, who underwent elective surgery from March 2013 to November 2014. Patients had surgery for Abdominal Aortic Aneurysm (AAA) or colorectal cancer. Delirium was scored prospectively using the Delirium Observation Screening Scale. Pre- and peri-operative predictors of delirium were analyzed using regression analysis. Outcomes after delirium included adverse events, length of hospital stay, discharge destination and mortality. Results We included 232 patients. 51 (22%) underwent surgery for AAA and 181 (78%) for colorectal cancer. Postoperative delirium occurred in 35 patients (15%). Predictors of postoperative delirium included: delirium in medical history (Odds Ratio 12 [95% Confidence Interval 2.7–50]), advancing age (Odds Ratio 2.0 [95% Confidence Interval 1.1–3.8]) per 10 years, and ASA-score ≥3 (Odds Ratio 2.6 [95% Confidence Interval 1.1–5.9]). Occurrence of delirium was related to an increase in adverse events, length of hospital stay and mortality. Conclusion Postoperative delirium is a frequent complication after major surgery in elderly patients and is related to an increase in adverse events, length of hospital stay, and mortality. A delirium in the medical history, advanced age, and ASA-score may assist in defining patients at increased risk for delirium. Further attention to prevention of delirium is essential in elderly patients undergoing major surgery.
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Affiliation(s)
- Jelle W. Raats
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
- * E-mail:
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