Exploration of Relationships Between Postoperative Pain and Subsyndromal Delirium in Older Adults

Transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program prevents subsyndromal delirium in older patients after joint replacement

OBJECTIVES

This study aimed to develop transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program and evaluate its effects on preventing subsyndromal delirium (SSD) and postoperative delirium (POD) in older patients after joint replacement surgery.

METHODS

Participants were randomly divided into two groups, the experimental group (n = 48) was given transcutaneous electrical acupoint stimulation combined with an integrated perioperative nursing program based on the routine care of the control group (n = 49). The incidence of SSD and POD in a week after surgery was recorded. Assessments of delirium severity, cognition, anxiety, and depression were also conducted at baseline and on postoperative day 7.

RESULTS

The findings indicate that the intervention program had significant advances in alleviating the severity of delirium, cognitive impairment, anxiety, and depression but failed to reduce the incidence of SSD and POD.

CONCLUSIONS

Our study indicated that TEAS combined with an integrated perioperative nursing program has a beneficial effect on alleviating symptoms of delirium, cognitive dysfunction, anxiety, and depression in older adults after joint replacement surgery.

The Age-adjusted Charlson Comorbidity Index predicts post-operative delirium in the elderly following thoracic and abdominal surgery: A prospective observational cohort study

Background

Post-operative delirium (POD) presents as a serious neuropsychiatric syndrome in the elderly undergoing thoracic and abdominal surgery, which is mostly associated with poor prognosis. The Age-adjusted Charlson Comorbidity Index (ACCI) has been widely recognized as an independently predictive factor for overall survival rate and mortality in various surgeries. However, no studies demonstrated the potential relationship between ACCI and POD. The current study was to explore the correlation between ACCI and POD, and determine the predictive effect of ACCI on POD in the elderly after thoracic and abdominal surgery.

Materials and methods

Total 184 patients (≥60 years) who underwent thoracic and abdominal surgery from 2021.10 to 2022.5 were enrolled in this prospective observational cohort study. ACCI was calculated by weighting comorbidities and age. POD was diagnosed using Confusion Assessment Method (CAM) twice a day in the first 3 days after surgery. The Visual Analog Scale (VAS) was applied to measure pre-operative and post-operative pain at rest and in motion. All demographic and perioperative data were compared in patients with POD and without POD. ACCI and other variables were analyzed by univariate and multivariate logistic regression analysis. The characteristic curve of receiver operating characteristic (ROC) was used to further evaluate the accuracy of ACCI to predict POD.

Results

Post-operative delirium was diagnosed in 36 of 184 patients included in our study. The prevalence of POD in the elderly after thoracic and abdominal surgery was 19.6%. The outcomes by multivariate regression analysis showed the independent risk factors for POD were ACCI (OR: 1.834; 95%CI: 1.434–2.344; P < 0.001), pre-operative Mini-Mental State Examination (MMSE) scores (OR: 0.873; 95%CI: 0.767–0.994; P = 0.040), serum albumin (OR: 0.909; 95%CI: 0.826–1.000; P = 0.049) and pain scores in the post-operative third day (OR: 2.013; 95%CI: 1.459–2.778; P < 0.001). ACCI can predict POD more accurately with the largest area under curve (AUC) of 0.794 and sensitivity of 0.861, respectively.

Conclusion

Age-adjusted Charlson Comorbidity Index, pre-operative MMSE scores, serum albumin and post-operative pain were independently associated with POD in geriatric patients following thoracic and abdominal surgery. Moreover, ACCI may become an accurate indicator to predict POD early.

Impact of combined epidural anaesthesia/analgesia on postoperative cognitive impairment in patients receiving general anaesthesia: a meta-analysis of randomised controlled studies

BACKGROUND

To investigate the efficacy of combined epidural anaesthesia/analgesia (EAA) against postoperative delirium/cognitive dysfunction (POD/POCD) in adults after major non-cardiac surgery under general anaesthesia (GA).

METHODS

The databases of PubMed, Google scholar, Embase and Cochrane Central Register were searched from inception to November 2021 for available randomised controlled trials (RCTs) that assessed the impact of EAA on risk of POD/POCD. The primary outcome was risk of POD/POCD, while the secondary outcomes comprised postoperative pain score, length of hospital stay (LOS), risk of complications, and postoperative nausea/vomiting (PONV).

RESULTS

Meta-analysis of eight studies with a total of 2376 patients (EAA group: 1189 patients; non-EAA group: 1187 patients) revealed no difference in risk of POD/POCD between the EAA and the non-EAA groups [Risk ratio (RR): 0.68; 95% CI: 0.41 to 1.13, p = 0.14, I² = 73%], but the certainty of evidence was very low. Nevertheless, the EAA group had lower pain score at postoperative 24 h [mean difference (MD): -1.49, 95% CI: -2.38 to -0.61; I² = 98%; five RCTs; n = 476] and risk of PONV (RR = 0.73, 95% CI: 0.57 to 0.93, p = 0.01, I² = 0%; three RCTs, 1876 patients) than those in the non-EAA group. Our results showed no significant impact of EAA on the pain score at postoperative 36-72 h, LOS, and risk of complications.

CONCLUSION

This meta-analysis demonstrated that EAA had no significant impact on the incidence of POD/POCD in patients following non-cardiac surgery.

Thoracic Paravertebral Block Ameliorates Postoperative Delirium in Geriatric Patients

OBJECTIVES

 Thoracic surgery often causes postoperative delirium (POD) in geriatric patients. This study aimed to explore the effect of ultrasound-guided continuous thoracic paravertebral block (UG-TPVB) on POD in geriatric patients undergoing pulmonary resection.

METHODS

 Total 128 patients who underwent pulmonary resection were randomly allocated to either the conventional patient-controlled analgesia (PCA) group or the UG-TPVB group (n = 64 per group). The consumption of opioid agents (propofol and remifentanil), postoperative hospital stay, postoperative pulmonary atelectasis, postoperative nausea/vomiting, and postoperative itchiness were recorded. The diagnosis of delirium was dependent on the Nursing Delirium Screening Scale. The postoperative pain was assessed by visual analogue scale (VAS) score. The serum levels of interleukin (IL)-1β, IL-6, and tumor necrosis factor-α were used to evaluate the postoperative neuroinflammation.

RESULTS

 The consumption of propofol and remifentanil, postoperative hospital stay, postoperative pulmonary atelectasis, postoperative nausea/vomiting, and postoperative itchiness in the UG-TPVB group were lower than that in the PCA group. Compared with the PCA group, the prevalence of POD was decreased in the UG-TPVB group. In addition, use of UG-TPVB not only reduced postoperative pain (VAS score) but also decreased postoperative neuroinflammation compared with PCA in geriatric patients undergoing pulmonary resection.

CONCLUSIONS

 This study determined the benefits of UG-TPVB over PCA, providing an effectiveness approach to alleviate POD in geriatric patients undergoing pulmonary resection.

Impact of dexmedetomidine supplemented analgesia on delirium in patients recovering from orthopedic surgery: A randomized controlled trial

Background

Dexmedetomidine promotes normal sleep architecture; the drug also improves analgesia. We therefore tested the hypothesis that supplementing intravenous analgesia with dexmedetomidine reduces delirium in older patients recovering from orthopedic surgery.

Methods

In this double-blinded randomized controlled trial, we enrolled 712 older (aged 65–90 years) patients scheduled for major orthopedic surgery. Postoperative analgesia was provided by patient-controlled intravenous sufentanil, supplemented by randomly assigned dexmedetomidine (1.25 μg/mL) or placebo, for up to three days. The primary outcome was the incidence of delirium assessed twice daily with the Confusion Assessment Method. Among secondary outcomes, pain severity was assessed twice daily and sleep quality once daily, each with an 11-point scale where 0 = no pain/the best possible sleep and 10 = the worst pain/the worst possible sleep.

Results

The incidence of postoperative delirium was 7.3% (26 of 354) with placebo and 4.8% (17 of 356) with dexmedetomidine; relative risk 0.65, 95% CI 0.36 to 1.18; P = 0.151. Dexmedetomidine reduced pain both at rest (median difference -1 to 0 points, P ≤ 0.001) and with movement (-1 points, P < 0.001) throughout the first 5 postoperative days; it also improved subjective sleep quality during the first 3 postoperative days: day one median difference -1 point (95% CI -1 to 0), P = 0.007; day two 0 point (-1 to 0), P = 0.010; and day three 0 point (-1 to 0), P = 0.003. The incidence of adverse events was similar in each group.

Conclusions

Supplementing sufentanil intravenous analgesia with low-dose dexmedetomidine did not significantly reduce delirium, but improved analgesia and sleep quality without provoking adverse events.

Trial registration

www.chictr.org.cn: ChiCTR1800017182 (Date of registration: July 17, 2018); ClinicalTrials.gov:NCT03629262 (Date of registration: August 14, 2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01441-3.

A narrative review of preventive measures for postoperative delirium in older adults

Postoperative delirium (POD) is an acute neurological condition associated with changes in cognition and attention and disorganised thinking. Although delirium can affect patients from any age group, it is common in older patients and could lead to a longer hospital stay and a higher risks of mortality. This article presents findings from a literature review that identifies various strategies used by health professionals globally to prevent POD. A database search resulted in 25 articles that met the inclusion criteria. Thematic analysis and coding were used to combine recurrent ideas that emerged from the literature. Three themes were identified: early identification and screening, modifiable risk factors, and preventive interventions. Further research focusing on education and improving awareness about POD among nurses is essential.

Subsyndromal Delirium in Cardiac Surgery Patients: Risk Factors and Outcomes of the Different Trajectories

BACKGROUND

Subsyndromal delirium (SSD), a subthreshold form of delirium, is related to longer length of stay and increased mortality rates among older adults. Risk factors and outcomes of SSD in cardiac surgery patients are not fully understood.

OBJECTIVE

The aim of this study was to assess and describe the characteristics and outcomes related to trajectories of SSD and delirium in cardiac surgery patients.

METHODS

In this secondary analysis of a retrospective case-control (1:1) cohort study, SSD was defined as a score between 1 and 3 on the Intensive Care Delirium Screening Checklist paired with an absence of diagnosis of delirium on the day of assessment. Potential risk factors (eg, age) and outcomes (eg, mortality) were identified from existing literature. Patients were grouped into 4 trajectories: (1) without SSD or delirium, (2) SSD only, (3) both, and (4) delirium only. These trajectories were contrasted using analysis of variance or χ2 test.

RESULTS

Among the cohort of 346 patients, 110 patients did not present with SSD or delirium, 62 presented with only SSD, 69 presented with both, and 105 presented with only delirium. In comparison with patients without SSD or delirium, patients with SSD presented preoperative risk factors known for delirium (ie, older age, higher European System for Cardiac Operative Risk Evaluation II) but underwent less complicated surgical procedures, received fewer transfusions postoperatively, and had a lower positive fluid balance postoperatively than patients who presented with delirium. Patients with both SSD and delirium had worse outcomes in comparison with those with delirium only.

CONCLUSION

This study stresses the importance for healthcare professionals to identify SSD and prevent its progression to delirium.

Preoperative Nutritional Status and Risk for Subsyndromal Delirium in Older Adults Following Joint Replacement Surgery

BACKGROUND

Subsyndromal delirium following surgery in older adults is related to increased lengths of hospital stay and increased admissions to long-term care. Impaired nutrition increases risk for delirium, but its relationship to subsyndromal delirium remains unclear.

PURPOSE

This correlational study examined the relationship between nutritional status and subsyndromal delirium in older adults.

METHODS

Assessments for subsyndromal delirium in 53 adults 65 years or older were completed for three consecutive days following joint replacement surgery. Relationships between nutritional status and subsyndromal delirium were analyzed. Level of significance for all tests was set at p ≤ .05.

RESULTS

Participants' scores from the Mini Nutritional Assessment screen were significantly related (p = .05) to subsyndromal delirium severity after accounting for variability posed by age and cognition status.

CONCLUSION

When preoperative risk assessment of older adults indicates nutritional risk, preoperative optimization may improve effectiveness of delirium prevention efforts.

Delirium in Internal Medicine Departments in a Tertiary Hospital in Israel: Occurrence, Detection Rates, Risk Factors, and Outcomes

Background: The aim of the study was to assess the occurrence rate of delirium among elderly hospitalized patients in the medicine wards of a large tertiary hospital, to identify risk factors, and to evaluate the diagnostic rate for delirium among the medical teams.

Methods: A 3-month prospective study of patients 65 years of age and above in three medicine wards: in two wards patients were examined by trained study team members using the Confusion Assessment Method (CAM), while the third was a control ward where CAM was not administered. The third ward served to control for the effect of the presence of investigators in the other wards as a potential confounding factor. Based on the results of this assessment patients were defined as suffering from subsyndromal delirium, full delirium (these two groups were later combined into an “any symptoms of delirium” group), and no delirium. The rate of diagnosis by the medical team was obtained from the electronic medical records.

Results: The full delirium rate was 5.1%, the rate of subsyndromal delirium was 14.6%, and the rate of any symptoms of delirium was 19.6%. Absence of a partner, pain, anemia, hyponatremia, hypocalcemia, and the use of drugs with an anticholinergic burden were factors for any symptoms of delirium as well as for subsyndromal delirium. Subsyndromal delirium and any symptoms of delirium were associated with a reduced chance of being discharged to home and a higher 3-month mortality rate. A diagnosis of delirium was found in only 19.4% of the patients with any symptoms of delirium in the medical records.

Conclusions: Delirium is a common problem among elderly hospitalized patients, but it is diagnosed sub-optimally by the medical team. There is a need for further training of the medical teams and implementation of delirium assessment as part of the ward's routine.

Comparison of Bispectral Index-Guided Individualized Anesthesia with Standard General Anesthesia on Inadequate Emergence and Postoperative Delirium in Elderly Patients Undergoing Esophagectomy: A Retrospective Study at a Single Center

Background

Elderly patients are susceptible to general anesthetics, with a higher bispectral index (BIS) at loss of consciousness (LOC) achieved by propofol infusion compared with young patients. Overexposure to general anesthetics can have adverse effects such as inadequate emergence and postoperative delirium (PD). This study aimed to compare the effects of BIS-guided individualized anesthesia with standard general anesthesia on emergence and delirium after esophagectomy.

Material/Methods

Data on 161 elderly patients undergoing esophagectomy for cancer were retrospectively obtained from electronic medical records. We performed propensity score matching analysis between patients receiving individualized anesthesia (BIS value maintained at about 10 less than the value at LOC) and those receiving standard anesthesia (BIS value maintained at 40–60). In addition, we conducted univariate and multivariate logistic analyses in the entire cohort.

Results

Patients receiving individualized anesthesia had higher BIS values and a lower propofol requirement during surgery than those receiving standard general anesthesia (P<0.05). The overall incidences of inadequate emergence and PD were 37.9% and 18.0% (n=161), respectively. Logistic regression analysis revealed that the independent risk factors for PD were organic brain disease (odds ratio [OR] 6.308; 95% confidence interval [CI] 2.458–16.187) and inadequate emergence (OR 4.063; 95% CI 1.645–10.033).

Conclusions

BIS-guided individualized anesthesia (lighter) does not reduce inadequate emergence or PD compared with standard general anesthesia in elderly patients undergoing esophagectomy. Independent risk factors for PD include organic brain disease and inadequate emergence.

Relationship Between Pain, Opioid Treatment, and Delirium in Older Emergency Department Patients

OBJECTIVES

Emergency department (ED) stay and its associated conditions (immobility, inadequate hydration and nutrition, lack of stimulation) increase the risk of delirium in older patients. Poorly controlled pain and paradoxically opioid pain treatment have also been identified as triggers for delirium. The aim of this study was to assess the relationship between pain, opioid treatment, and delirium in older ED patients.

METHODS

A multicenter prospective cohort study was conducted in four hospitals across the province of Québec (Canada). Patients aged ≥ 65 years old, waiting for hospital admission between March and July 2015, who were nondelirious upon ED arrival, who were independent or semi-independent in their daily living activities, and who had an ED stay of at least 8 hours were included. Delirium assessments were conducted twice a day during the patient's entire ED stay and their first 24 hours on the hospital ward using the Confusion Assessment Method. Pain intensity was evaluated using a visual analog scale (VAS = 0-100) during the initial interview, and all opioid treatments were documented.

RESULTS

A total of 338 patients were included; 51% were female, and mean (±SD) age was 77 (±8) years. Forty-one patients (12%) experienced delirium during their hospital stay occurring within a mean (±SD) delay of 47 (±19) hours after ED admission. Among patients with pain intensity ≥ 65 from VAS (0-100), 26% experienced delirium compared to 11% for patients with pain < 65 (p < 0.01), and no significant association was found between opioid consumption and delirium (p = 0.31). Logistic regression controlling for confounding factors showed that patients with pain intensity ≥ 65 are 3.3 (95% confidence interval = 1.4 to 7.9) times more likely to develop delirium than patients who had pain intensity of <65.

CONCLUSIONS

Severe pain, not opioids, is associated with the development of delirium during ED stay. Adequate pain control during the hospital stay may contribute to a decrease in delirium episodes.

Ultrasound-guided continuous thoracic paravertebral block alleviates postoperative delirium in elderly patients undergoing esophagectomy: A randomized controlled trial

BACKGROUND

Delirium is a common postoperative complication in older patients undergoing thoracic surgery and presages poor outcomes. Postoperative pain is an important factor in the progression of delirium. The purpose of this study was to test whether continuous thoracic paravertebral block (PVB), a more effective approach for analgesia, could decrease the incidence of delirium in elderly patients undergoing esophagectomy.

METHODS

A total of 180 geriatric patients undergoing esophagectomy were randomly divided into 2 groups and treated with PVB or patient-controlled analgesia (PCA). Perioperative plasma CRP, IL-1β, IL-6, and TNF-α levels were detected in all patients. Pain intensity was measured by a numerical rating scale. Delirium was assessed using the confusion assessment method.

RESULTS

The incidence of postoperative delirium was significantly lower in the PVB group than in the PCA group. Patients in the PVB group had lower plasma CRP, IL-1β, IL-6, and TNF-α levels and less pain when coughing after surgery.

CONCLUSIONS

Ultrasound-guided continuous thoracic paravertebral block improved analgesia, reduced the inflammatory reaction and decreased the occurrence of delirium after surgery.

Pain Screening in the Older Adult With Delirium

BACKGROUND

In patients with cognitive impairments who are unable to self-report pain, nurses must rely on behavioral observation tools to assess and manage pain. Although frequently employed in medical-surgical units, evidence supporting the psychometric efficacy of the Pain in Advanced Dementia (PAINAD) for pain screening in older adults with delirium is lacking.

AIM

To examine the psychometrics of the PAINAD for older adults with delirium in medical-surgical settings.

DESIGN

A descriptive repeated measures design.

SETTING

Medical-surgical units in an urban tertiary care hospital.

PARTICIPANTS

Sixty-eight older adults with delirium.

METHODS

Patients with delirium unable to self-report pain were screened by two data collectors with the PAINAD and the Critical Care Pain Observation Tool (CPOT). Patients with a PAINAD score ≥3 or a CPOT score ≥2 received a pain intervention. Pain assessments were repeated 30 minutes post baseline or pain intervention.

RESULTS

Patients were predominately female (58.8%) with dementia (71%). Thirty-nine patients screened positive for pain and received a pain intervention. PAINAD reliability was strong (Cronbach's α = 0.81-0.87; interrater intraclass coefficients [ICC] = 0.91-0.94; test-retest ICC = 0.76-0.77). Construct validity was supported by a statistically significant interaction effect between time (baseline versus follow-up) and condition (pain intervention versus no pain group; Rater 1: F(1,66) = 8.31, p = 0.005, η_p² = 0.11; Rater 2: F(1,66) = 8.22, p = 0.006, η_p² = 0.11.

CONCLUSIONS

The PAINAD is a reliable and valid tool for pain screening for older adults with delirium in medical-surgical settings.

CLINICAL IMPLICATIONS

Pain and delirium frequently co-occur in the older adult population. Best practices require a holistic assessment for contributing pain and non-pain factors in patients exhibiting distress.

Pain, Opioid Intake, and Delirium Symptoms in Adults Following Joint Replacement Surgery

This study examined the effects of pain and opioid intakes on subsyndromal delirium in older adults who had joint replacement surgery. Delirium assessments of 53 older adults were completed on the first, second, and third days following joint replacement surgery using the Confusion Assessment Method (CAM). Statistical relationships were analyzed using correlations and multiple regressions. Subsyndromal delirium developed in 68% (n = 36) of participants. Pain was significantly related (p < .05) to increased delirium symptoms after accounting for preoperative risk factors of comorbidity, cognitive status, fall history, and preoperative fasting times, whereas opioid intake was not significantly associated with increased delirium symptoms. Findings suggest older adults with increased pain levels are at higher risk for subsyndromal delirium as well as delirium after joint replacement surgery.