Retrospective comparison of the effects of remimazolam and dexmedetomidine on postoperative delirium in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia

PURPOSE

Remimazolam is often used for perioperative sedation due to its rapid onset and offset. However, the possible association between remimazolam and postoperative delirium (POD) remains undetermined. The present study evaluated whether remimazolam increased the incidence of POD compared with dexmedetomidine in elderly patients undergoing orthopedic surgery of the lower extremities.

METHODS

This retrospective study included patients aged ≥ 65 years who had undergone orthopedic surgery of the lower extremities under spinal anesthesia from January 2020 to November 2022 and were sedated with continuous intravenous infusion of dexmedetomidine or remimazolam. The incidence of POD was assessed through a validated comprehensive review process of each patient's medical records. The effect of remimazolam on the occurrence of POD compared with dexmedetomidine was evaluated by propensity score weighted multivariable logistic models.

RESULTS

A total of 447 patients were included in the final analysis. The crude incidence of POD within 3 days after surgery was 7.5% (17/226) in the dexmedetomidine group and 11.8% (26/221) in the remimazolam group, increasing to 9.7% (22/226) and 15.8% (35/221), respectively (p = 0.073), within 5 days. The multivariable models showed that, compared with dexmedetomidine, intraoperative sedation with remimazolam significantly increased the occurrence of POD within 3 days (odds ratio [OR] 2.21, 95% confidence interval [CI] 1.31 to 3.82, p = 0.003) and 5 days (OR 2.10, 95% CI 1.32 to 3.40, p = 0.002).

CONCLUSION

Compared with dexmedetomidine, remimazolam infusion may be associated with a higher risk of POD in elderly patients undergoing orthopedic surgery of the lower extremities under spinal anesthesia.

Diagnostic Accuracy of the Recognizing Acute Delirium as Part of Your Routine (RADAR) Scale for Delirium Assessment in Hospitalized Older Adults: A Cross-Sectional Study

Delirium is highly prevalent among hospitalized older adults and is associated with unfavorable outcomes. However, delirium often remains undiagnosed in the hospital context. Having a valid, simple, and fast screening tool could help in limiting the additional workload for healthcare professionals, without leaving delirium undetected. The aim of this study was to estimate the sensitivity and specificity of the Recognizing Acute Delirium As part of your Routine (RADAR) scale in an Italian hospital. An observational cross-sectional study was conducted. A total of 150 patients aged ≥70 years were enrolled. Receiver operating characteristic (ROC) curves using the Confusion Assessment Method (CAM) criterion-defined delirium as the gold standard were plotted to evaluate the performance of the RADAR scale. The cut-off suggested by previous research was used to estimate the sensitivity, specificity, and positive and negative predictive values of the RADAR scale. The involved patients were mostly females (60%; n = 90), with a median age of 84 years (I-III quartiles: 80-88). According to the CAM and the RADAR scale, 37 (25%) and 58 (39%) patients were classified as experiencing delirium, respectively. The area under the ROC curve of the RADAR scale was 0.916. Furthermore, the RADAR scale showed robust sensitivity (95%), specificity (80%), and positive (60%) and negative predictive values (98%). The RADAR scale is thus suggested to be a valid tool for screening assessment of delirium in hospitalized older adults.

Predicting postoperative delirium after percutaneous transluminal angioplasty and stenting in patients with intracranial atherosclerotic stenosis

OBJECTIVE

Known as a major surgical complication, postoperative delirium (POD) has not been well studied in patients with intracranial atherosclerotic stenosis (ICAS). This study aimed to investigate the correlation between perioperative clinical characteristics and the occurrence of POD.

METHODS

Patients' demographic characteristics and perioperative testing data were collected. Binary logistic regression was conducted for assessing related risk factors. A nomogram was developed to predict the occurrence of POD after percutaneous transluminal angioplasty and stenting (PTAS) in patients with ICAS.

RESULTS

The occurrence of POD in this study was 30.67%. Among all the clinical and laboratory characteristics in patients, age (OR = 1.234, 95%CI = 1.004-1.517, p = 0.046), gender (OR = 5.676, 95%CI = 1.028-31.334, p = 0.046), preoperative MMSE scores (OR = 2.298, 95%CI = 1.005-5.259, p = 0.049), the degree of stenosis (OR = 6.294, 95%CI = 1.043-37.974, p = 0.045), operating time (OR = 1.088, 95%CI = 1.023-1.157, p = 0.006), and HbA1c levels (OR = 2.226, 95%CI = 1.199-4.130, p = 0.011) were the independent risk factors.

CONCLUSION

Male patients with advanced-age, lower preoperative MMSE scores, severe stenosis, longer operating time, and higher HbA1c levels are closely related to POD after PTAS. Fully perioperative assessments may play an important role in predicting the occurrence of POD.

Cognitive trajectories after surgery: Guideline hints for assessment and treatment

Elderly patients who undergo major surgery (not-neurosurgical) under general anaesthesia frequently complain about cognitive difficulties, especially during the first weeks after surgical "trauma". Although recovery usually occurs within a month, about one out of four patients develops full-blown postoperative Neurocognitive disorders (NCD) which compromise quality of life or daily autonomy. Mild/Major NCD affect approximately 10% of patients from three months to one year after major surgery. Neuroinflammation has emerged to have a critical role in the postoperative NCDs pathogenesis, through microglial activation and the release of pro-inflammatory cytokines which increase blood-brain-barrier permeability, enhance movement of leukocytes into the central nervous system (CNS) and favour the neuronal damage. Moreover, pre-existing Mild Cognitive Impairment, alcohol or drugs consumption, depression and other factors, together with several intraoperative and post-operative sequelae, can exacerbate the severity and duration of NCDs. In this context it is crucial rely on current progresses in serum and CSF biomarker analysis to frame neuroinflammation levels, along with establishing standard protocol for neuropsychological assessment (with specific set of tools) and to apply cognitive training or neuromodulation techniques to reduce the incidence of postoperative NCDs when required. It is recommended to identify those patients who would need such preventive intervention early, by including them in pre-operative and post-operative comprehensive evaluation and prevent the development of a full-blown dementia after surgery. This contribution reports all the recent progresses in the NCDs diagnostic classification, pathogenesis discoveries and possible treatments, with the aim to systematize current evidences and provide guidelines for multidisciplinary care.

Causal relationship between dementia and delirium: Insights from a bidirectional two-sample Mendelian randomization analysis

BACKGROUND

Our previous study found dementia as a significant risk factor for delirium development in elderly patients with hip fracture. However, the causal relationship between dementia and delirium remains unclear.

METHODS

To assess the causal relationship between delirium and dementia, we conducted a bidirectional Mendelian randomization (MR) analysis. Inversevariance weighted (IVW), weighted median, MR Egger, weighted mode, and simple mode were employed to conduct the MR analysis. Heterogeneity was assessed using the Cochran Q statistic in MR-Egger and IVW methods. Horizontal pleiotropy was examined via the MR pleiotropy residual sum and outliers (MR-PRESSO) and MR-Egger intercept tests.

RESULTS

The forward MR analysis revealed a significant association between unclassified dementia (1.604 (1.326-1.941), p = 1.12 × 10-6), Alzheimer's disease (1.259 (1.128-1.405), p = 4.10 × 10-5), and dementia with Lewy bodies (1.121 (1.026-1.225), p = 0.011) with an increased risk of delirium. In the reverse MR analysis, delirium was also suggested to increase the risk of unclassified dementia (1.133 (1.066-1.204), p = 6.31 × 10-5) and vascular dementia (1.246 (1.075-1.444), p = 0.003). These significant results were further validated in the multivariable MR analysis. No evidence of heterogeneity or horizontal pleiotropy was observed (p > 0.05).

LIMITATIONS

(1) Limited to European populations. (2) Sample population overlap between delirium and dementia. (3) Not all dementia subtypes were causally associated with delirium.

CONCLUSIONS

This study provides genetic evidence supporting a causal relationship between dementia and delirium, indicating that dementia may influence the risk of delirium while delirium may also increase the risk of dementia.

A cluster-randomized controlled trial of a nurse-led artificial intelligence assisted prevention and management for delirium (AI-AntiDelirium) on delirium in intensive care unit: Study protocol

BACKGROUND

Delirium is a common complication among intensive care unit (ICU) patients that is linked to negative clinical outcomes. However, adherence to the Clinical Practice Guidelines for the Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility, and Sleep Disruption in Adult Patients in the ICU (PADIS guidelines), which recommend the use of the ABCDEF bundle, is sub-optimal in routine clinical care. To address this issue, AI-AntiDelirium, a nurse-led artificial intelligence-assisted prevention and management tool for delirium, was developed by our research team. Our pilot study yielded positive findings regarding the use of AI-AntiDelirium in preventing patient ICU delirium and improving activities of daily living and increasing intervention adherence by health care staff.

METHODS

The proposed large-scale pragmatic, open-label, parallel-group, cluster randomized controlled study will assess the impact of AI-AntiDelirium on the incidence of ICU delirium and delirium-related outcomes. Six ICUs in two tertiary hospitals in China will be randomized in a 1:1 ratio to an AI-AntiDelirium or a PADIS guidelines group. A target sample size of 1,452 ICU patients aged 50 years and older treated in the ICU for at least 24 hours will be included. The primary outcome evaluated will be the incidence of ICU delirium and the secondary outcomes will be the duration of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, patient activities of daily living, and ICU nurse adherence to the ABCDEF bundle.

DISCUSSION

If this large-scale trial provides evidence of the effectiveness of AI-AntiDelirium, an artificial intelligence-assisted system tool, in decreasing the incidence of ICU delirium, length of ICU and hospital stay, ICU and in-hospital mortality rates, patient cognitive function, and patient activities of daily living while increasing ICU nurse adherence to the ABCDEF bundle, it will have a profound impact on the management of ICU delirium in both research and clinical practice.

CLINICAL TRIAL REGISTRATION

ChiCTR1900023711 (Chinese Clinical Trial Registry).

Risk prediction models for postoperative delirium in elderly patients with fragility hip fracture: A systematic review and critical appraisal

BACKGROUND

Elderly patients with fragility hip fracture continue to experience a high rate of postoperative delirium (POD), which has a significant negative impact on prognosis and imposes a huge economic burden. A number of risk prediction models have been developed to detect POD early. However, the risk of bias and clinical applicability of the models remain unclear. The aim of this study was to systematically evaluate risk prediction models for POD.

METHODS

CNKI, WanFang DATA, Vip Database, SinoMed, PubMed, Web of Science, Embase, and the Cochrane Library were searched for studies published by July 2023. The literature was screened independently by two investigators. The Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies (CHARMS) and the Prediction Model Risk of Bias Assessment Tool (PROBAST) were respectively used for data extraction, risk of bias, and applicability assessment.

RESULTS

A total of 16 studies on the construction of POD risk prediction models were included. The area under the ROC curve of the models ranges from 0.670 to 0.957. The most common predictors of POD included age, history of dementia, history of delirium, ASA classification, preoperative waiting time, and preoperative albumin level. All models had a high risk of bias, mainly due to inadequate sample size, inappropriate handling of missing data, a lack of model performance evaluation, and overfitting of the models.

CONCLUSIONS

Overall, risk prediction models for POD in fragility hip fracture patients are still in the development stage. The majority of POD prediction models have substantial bias risks, attributable primarily to poor reporting of analysis and evaluation of model performance. In future research, it is recommended to conduct validation of the models or develop localized prediction models with demonstrated high performance, with the aim of benefiting POD screening.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023449153.

Association of preoperative frailty with the risk of postoperative delirium in older patients undergoing hip fracture surgery: a prospective cohort study

OBJECTIVE

This study aimed to explore the correlation between preoperative frailty and the risk of postoperative delirium (POD) in older patients undergoing hip fracture surgery.

METHODS

In total, 148 patients with hip fractures who were admitted to Tsinghua Changgung Hospital (Beijing, China) between January 2022 and January 2023 were involved in this study. Preoperative frailty scales were assessed, of which the CAM scale was postoperatively administered every morning and evening on days 1, 2, 3, 5, and 7. Binary logistic regression analysis was conducted to determine the correlation between preoperative frailty and the risk of POD.

RESULTS

Among 148 older patients with hip fractures, 71 (48.0%) were identified as preoperative frail and 77 (52.0%) as non-frail. The overall incidence of POD on day 7 was 24.3% (36/148), and preoperative frailty was associated with a significantly higher risk of POD compared with non-frailty (42.3% vs. 7.8%, P < 0.001). The binary logistic regression analysis revealed that preoperative frailty was noted as an independent risk factor for the risk of POD in older patients undergoing hip fracture surgery (P = 0.002).

CONCLUSION

Preoperative frailty increased the risk of POD in older patients undergoing hip fracture surgery.

DISCUSSION

Preoperative assessment of frailty in geriatric hip surgery can timely identify potential risks and provide interventions targeting frailty factors to reduce the incidence of POD in older patients undergoing hip fracture surgery. The findings suggested that preoperative frailty could increase the risk of POD in older patients undergoing hip fracture surgery. Further research is necessary to determine whether perioperative interventions aimed at enhancing frailty can mitigate the risk of POD and improve prognosis in older patients undergoing hip fracture surgery.

Reduction of Postoperative Delirium and Opioid Use in Hip Fracture Patients Through Utilization of Emergency Department Physician Administered Regional Nerve Blocks

Introduction

The complication of delirium for hip fracture patients is a predictor of mortality. Use of opioid medication increases the incidence of delirium in the pre- and postoperative periods. Regional nerve blocks are effective in managing acute pain for acute hip fractures. This study aims to evaluate the utilization of ED physicians to perform fascia iliaca nerve blocks on hip fracture patients to decrease the incidence of delirium by decreasing usage of opioid medication.

Methods

A quality improvement project for performing regional nerve blocks on patients with femoral neck fractures was implemented during fiscal year 2019. Data was collected retrospectively for frequency of ED nerve block procedures, amount of opioid medication use, and incidence of delirium in patients diagnosed with hip fracture. This data was compared to baseline data to determine success of the intervention.

Results

Utilization of regional nerve blocks in the ED increased from 2% in 2018 to 96% in 2021 and 89% in 2022. Preoperative opioid usage decreased from 38 MMEs to 16.9 and 18 MMEs respectively. Daily average MMEs decreased from 34 to 12.1 and 14 respectively. Postoperative delirium decreased from 6% in 2018 to 0% from 2020 to 2022.

Discussion

ED provider administration of fascia iliaca blocks and follow-up is a novel practice in our region to decrease the adverse effects of opiate use and decrease delirium rates. There was a reduction in length of stay and increased discharge home rate despite the Covid-19 pandemic.

Conclusion

Administration of regional nerve blocks by ED physicians to hip fracture patients presenting to the ED results in a decrease in opioid medication usage. This also results in a decreased delirium rates in the hip fracture patient population.

Advancing specificity in delirium: The delirium subtyping initiative

BACKGROUND

Delirium, a common syndrome with heterogeneous etiologies and clinical presentations, is associated with poor long-term outcomes. Recording and analyzing all delirium equally could be hindering the field's understanding of pathophysiology and identification of targeted treatments. Current delirium subtyping methods reflect clinically evident features but likely do not account for underlying biology.

METHODS

The Delirium Subtyping Initiative (DSI) held three sessions with an international panel of 25 experts.

RESULTS

Meeting participants suggest further characterization of delirium features to complement the existing Diagnostic and Statistical Manual of Mental Disorders Fifth Edition Text Revision diagnostic criteria. These should span the range of delirium-spectrum syndromes and be measured consistently across studies. Clinical features should be recorded in conjunction with biospecimen collection, where feasible, in a standardized way, to determine temporal associations of biology coincident with clinical fluctuations.

DISCUSSION

The DSI made recommendations spanning the breadth of delirium research including clinical features, study planning, data collection, and data analysis for characterization of candidate delirium subtypes.

HIGHLIGHTS

Delirium features must be clearly defined, standardized, and operationalized. Large datasets incorporating both clinical and biomarker variables should be analyzed together. Delirium screening should incorporate communication and reasoning.

Frailty and post-operative delirium influence on functional status in patients with hip fracture: the GIOG 2.0 study

BACKGROUND

This study analyzes the effect of frailty and Post-Operative Delirium (POD) on the functional status at hospital discharge and at 4-month follow-up in patients with hip fracture (HF).

METHODS

Multicenter prospective observational study of older patients with HF admitted to 12 Italian Orthogeriatric centers (July 2019-August 2022). POD was assessed using the 4AT. A 26-item Frailty Index (FI) was created using data collected on admission. The outcome measures were Cumulated Ambulation Score (CAS) ≤ 2 at discharge and a telephone-administered CAS ≤ 2 after 4 months. Poisson regression models were used to assess the effect of frailty and POD on outcomes.

RESULTS

984 patients (median age 84 years, IQR = 79-89) were recruited: 480 (48.7%) were frail at admission, 311 (31.6%) developed POD, and 158 (15.6%) had both frailty and POD. In a robust Poisson regression, frailty alone (Relative Risk, RR = 1.56, 95% Confidence Intervals, CI 1.19-2.04, p = 0.001) and its combination with POD (RR = 2.57, 95% CI 2.02-3.26, p < 0.001) were associated with poor functional status at discharge. At 4-month follow-up, the combination of frailty with POD (RR 3.65, 95% CI 1.85-7.2, p < 0.001) increased the risk of poor outcome more than frailty alone (RR 2.38, 95% CI 1.21-4.66, p < 0.001).

CONCLUSIONS

POD development exacerbates the negative effect that frailty exerts on functional outcomes in HF patients.

Risk factors associated with postoperative delirium in elderly patients undergoing hip surgery

Objective

We retrospectively analyzed the occurrence of postoperative delirium following hip surgery and the associated risk factors. The aim was to establish a clinical foundation for preventing postoperative delirium after hip surgery.

Methods

We retrospectively selected elderly patients who had hip surgery at our hospital between January 2022 and August 2022. We included patients who experienced delirium in the observation group and those who did not encounter delirium in the control group. We then proceeded to compare various indicators among these two groups of patients.

Results

We analyzed a total of 97 cases of hip surgery, and among them, 32 cases experienced postoperative delirium, resulting in an incidence rate of 32.9%. Various factors were found to be linked to the development of postoperative delirium, including age, height, gender (male), preoperative erythrocyte sedimentation rate (ESR), postoperative ESR, preoperative lactate levels, pain scores on the first day after surgery, type of surgical procedure, and the occurrence of delirium in the post-anesthesia care unit (PACU delirium). Additionally, it was observed that 75% of patients who had PACU delirium also experienced postoperative delirium.

Conclusion

Postoperative delirium in patients who have hip surgery had an incidence rate of 32.9%. This phenomenon is linked to various factors that pose a risk, such as the patient age, height, gender, preoperative ESR levels, postoperative ESR levels, preoperative lactate levels, pain scores on the day following surgery, and the specific surgical procedure performed. The likelihood of experiencing delirium increases by 12% for every additional 10 years in patient age. Additionally, the occurrence of delirium in the PACU is a strong indicator of the likelihood of experiencing postoperative delirium.

Comparative Effectiveness of Dual- Versus Mono-Sedative Therapy on Opioid Administration, Sedative Administration, and Sedation Level in Mechanically Ventilated, Critically Ill Children

OBJECTIVE

We estimated the effect of early initiation of dual therapy vs monotherapy on drug administration and related outcomes in mechanically ventilated, critically ill children.

METHODS

We used the electronic medical record at a single tertiary medical center to conduct an active comparator, new user cohort study. We included children <18 years of age who were exposed to a sedative or analgesic within 6 hours of intubation. We used stabilized inverse probability of treatment weighting to account for confounding at baseline. We estimated the average effect of initial dual therapy vs monotherapy on outcomes including cumulative opioid, benzodiazepine, and dexmedetomidine dosing; sedation scores; time to double the opioid or benzodiazepine infusion rate; initiation of neuromuscular blockade within the first 7 days of follow-up; time to extubation; and 7-day all-cause in-hospital death.

RESULTS

The cohort included 640 patients. Children receiving dual therapy received 0.03 mg/kg (95% CI, 0.02-0.04) more dexmedetomidine over the first 7 days after initiation of mechanical ventilation than did monotherapy patients. Dual therapy patients had similar sedation scores, time to double therapy, initiation of neuromuscular blockade, and time to extubation as monotherapy patients. Dual therapy patients had a lower incidence of death.

CONCLUSIONS

In this study, initial dual therapy compared with monotherapy does not reduce overall drug administration during mechanical ventilation. The identified effect of dual therapy on mortality deserves further investigation.

Resting-state prefrontal EEG biomarker in correlation with postoperative delirium in elderly patients

Postoperative delirium (POD) is associated with adverse outcomes in elderly patients after surgery. Electroencephalography (EEG) can be used to develop a potential biomarker for degenerative cerebral dysfunctions, including mild cognitive impairment and dementia. This study aimed to explore the relationship between preoperative EEG and POD. We included 257 patients aged >70 years who underwent spinal surgery. We measured the median dominant frequency (MDF), which is a resting-state EEG biomarker involving intrinsic alpha oscillations that reflect an idle cortical state, from the prefrontal regions. Additionally, the mini-mental state examination and Montreal cognitive assessment (MoCA) were performed before surgery as well as 5 days after surgery. For long-term cognitive function follow up, the telephone interview for cognitive status™ (TICS) was performed 1 month and 1 year after surgery. Fifty-two (20.2%) patients were diagnosed with POD. A multivariable logistic regression analysis that included age, MoCA score, Charlson comorbidity index score, Mini Nutritional Assessment, and the MDF as variables revealed that the MDF had a significant odds ratio of 0.48 (95% confidence interval 0.27-0.85). Among the patients with POD, the postoperative neurocognitive disorders could last up to 1 year. Low MDF on preoperative EEG was associated with POD in elderly patients undergoing surgery. EEG could be a novel potential tool for identifying patients at a high risk of POD.

Outcomes with spinal versus general anesthesia for patients with and without preoperative cognitive impairment: Secondary analysis of a randomized clinical trial

INTRODUCTION

The effect of spinal versus general anesthesia on the risk of postoperative delirium or other outcomes for patients with or without cognitive impairment (including dementia) is unknown.

METHODS

Post hoc secondary analysis of a multicenter pragmatic trial comparing spinal versus general anesthesia for adults aged 50 years or older undergoing hip fracture surgery.

RESULTS

Among patients randomized to spinal versus general anesthesia, new or worsened delirium occurred in 100/295 (33.9%) versus 107/283 (37.8%; odds ratio [OR] 0.85; 95% confidence interval [CI] 0.60 to 1.19) among persons with cognitive impairment and 70/432 (16.2%) versus 71/445 (16.0%) among persons without cognitive impairment (OR 1.02; 95% CI 0.71 to 1.47, p = 0.46 for interaction). Delirium severity, in-hospital complications, and 60-day functional recovery did not differ by anesthesia type in patients with or without cognitive impairment.

DISCUSSION

Anesthesia type is not associated with differences in delirium and functional outcomes among persons with or without cognitive impairment.

Postoperative delirium after cholecystectomy in older patients: A retrospective study

Backgrounds/Aims

Postoperative delirium (POD) is a common complication that increases mortality and morbidity in older patients. This study aimed to evaluate the clinical significance of post-cholecystectomy delirium in older patients.

Methods

This retrospective study included 201 patients aged > 75 years who underwent cholecystectomy for acute or chronic cholecystitis between January 2016 and December 2019. Patients were divided into the POD (n = 21) and non-POD (n = 180) groups, and their demographic features and clinical results were compared.

Results

The mean patient age was 78.88 years; the female/male ratio was 44.8%/55.2%. Laparoscopic surgery was performed in 93.5% of patients. The univariate analysis showed that lower body mass index (BMI), immobilized admission status, neuropsychiatric disease history, preoperative intervention (percutaneous drainage), high C-reactive protein, hypoalbuminemia, neutrophilia, hypo-/hyperkalemia, and longer operative time were more frequently observed in the POD group. The multivariate analysis showed that lower BMI (odds ratio [OR], 2.796; p = 0.024), neuropsychiatric disease history (OR, 3.019; p = 0.049), hyperkalemia (OR, 5.972; p = 0.007), and longer operative time (OR, 1.011; p = 0.013) were significant risk factors for POD.

Conclusions

POD was associated with inflammation degree, general condition, poor nutritional status, electrolyte imbalance, and stressful conditions. Recognizing risk factors requiring multidisciplinary team approaches is important to prevent and treat POD.

Incidence of postoperative delirium in older adults undergoing surgical procedures: A systematic literature review and meta-analysis

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.

The impact of postoperative cognitive impairment on mid-term survival after heart transplantation

BACKGROUND

Heart transplantation is the definitive therapy for patients with end-stage heart failure. Antecedent studies reported that a substantial proportion of heart transplant recipients developed postoperative cognitive impairment in the long term. However, no studies have explored the association between postoperative cognitive impairment and survival after heart transplantation.

METHODS

The data of 43 adult patients who underwent heart transplantation were consecutively enrolled and assessed using the MMSE and MoCA neuropsychological tests. Kaplan-Meier curves and Cox proportional hazards models were used for survival analyses. Primary component analysis was performed to integrate MoCA subtests into the "Attention factor," "Naming factor," and "Orientation factor."

RESULTS

About 30% of the patients were diagnosed with short-term postoperative cognitive impairment. The impairment group was older and had lower baseline cognitive performances, larger LV diameter, worse MMSE decline and higher ratio of significant MoCA decline. Postoperative cognitive impairment was significantly associated with worse survival (P = .028). Multivariate Cox analyses showed that higher postoperative MoCA score was significantly associated with lower mid-term post-transplant mortality (HR = .744 [.584, .949], P = .017), in which "Attention factor" contributed to this association most (HR = .345 [.123, .970], P = .044) rather than "Naming factor" or "Orientation factor." Notably, preoperative cognitive impairment was closely related with postoperative cognitive impairment and also indicated the worse post-transplant survival (P = .015).

CONCLUSION

Postoperative as well as preoperative cognitive impairments were associated with a worse mid-term survival after heart transplantation, indicating that neuropsychological assessments before and after heart transplantation should be routinely performed for heart transplant recipients for better risk stratification.

Delirium After Surgery for Proximal Femoral Fractures in the Frail Elderly Patient: Risk Factors and Clinical Outcomes

Purpose

The primary aim of this study was to identify risk factors for delirium after hip fracture surgery. The secondary purpose of this study was to verify peri-operative clinical outcomes, adverse events and mortality rates in delirium patients after hip fracture surgery.

Patients and Methods

A prospective hip fracture database was used to obtain data. In total, 2051 patients older than 70 years undergoing a hip fracture surgery between 01-01-2018 and 01-01-2021 were included. A delirium was diagnosed by a geriatrician based on the DSM-V criteria.

Results

The results showed that 16% developed a delirium during hospital admission. Multivariable analysis showed that male gender (OR: 1.99, p<0.001), age (OR: 1.06, p<0.001), dementia (OR: 1.66, p=0.001), Parkinson's disease (OR: 2.32, p=0.001), Δhaemoglobin loss (OR: 1.19, p=0.022), pneumonia (OR: 3.86, p<0.001), urinary tract infection (UTI) (OR: 1.97, p=0.001) and wound infection (OR: 3.02, p=0.007) were significant independent prognostic risk factors for the development of a delirium after hip surgery. The median length in-hospital stay was longer in patients with a delirium (9 days) vs patients without a delirium (6 days) (p<0.001). The 30-day mortality was 7% (with delirium 16% vs with no delirium 6% (p<0.001)).

Conclusion

Significant independent prognostic factors associated with delirium after hip surgery were male gender, age, dementia, Parkinson's disease, Δhaemoglobin loss, pneumonia, UTI and wound infection.

Association between COVID-19 and Postoperative Neurological Complications and Antipsychotic Medication Use after Cancer Surgery: A Retrospective Study

INTRODUCTION

Millions of Americans infected with the severe acute respiratory syndrome-associated coronavirus-19 (COVID-19) need oncologic surgery. Patients with acute or resolved COVID-19 illness complain of neuropsychiatric symptoms. How surgery affects postoperative neuropsychiatric outcomes such as delirium is unknown. We hypothesize that patients with a history of COVID-19 could have an exaggerated risk of developing postoperative delirium after undergoing major elective oncologic surgery.

METHODS

We conducted a retrospective study to determine the association between COVID-19 status and antipsychotic drugs during postsurgical hospitalization as a surrogate of delirium. Secondary outcomes included 30 days of postoperative complications, length of stay, and mortality. Patients were grouped into pre-pandemic non-COVID-19 and COVID-19-positive groups. A 1:2 propensity score matching was used to minimize bias. A multivariable logistic regression model estimated the effects of important covariates on the use of postoperative psychotic medication.

RESULTS

A total of 6003 patients were included in the study. Pre- and post-propensity score matching demonstrated that a history of preoperative COVID-19 did not increase the risk of antipsychotic medications postoperatively. However, respiratory and overall 30-day complications were higher in COVID-19 individuals than in pre-pandemic non-COVID-19 patients. The multivariate analysis showed that the odds of using postoperative antipsychotic medication use for the patients who had COVID-19 compared to those who did not have the infection were not significantly different.

CONCLUSION

A preoperative diagnosis of COVID-19 did not increase the risk of postoperative antipsychotic medication use or neurological complications. More studies are needed to reproduce our results due to the increased concern of neurological events post-COVID-19 infection.

Prediction models for postoperative delirium after cardiac surgery: Systematic review and critical appraisal

BACKGROUND

Many studies have developed or validated prediction models to estimate the risk of delirium after cardiac surgery, but the quality of the model development and model applicability remain unknown.

OBJECTIVES

To systematically review and critically evaluate currently available prediction models for delirium after cardiac surgery.

DATA SOURCES

PubMed, EMBASE, and MEDLINE were systematically searched. This systematic review was registered in PROSPERO (Registration ID: CRD42021251226).

STUDY SELECTION

Prospective or retrospective cohort studies were considered eligible if they developed or validated prediction models or scoring systems for delirium in the ICU. We included studies involving adults (age ≥18 years) undergoing cardiac surgery and excluded studies that did not validate a prediction model.

DATA EXTRACTION

Data extraction was independently performed by two authors using a standardized data extraction form based on the Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies checklist. Quality of the models was assessed with the Prediction Model Risk of Bias Assessment Tool (PROBAST).

DATA SYNTHESIS

Of 5469 screened studies, 13 studies described 10 prediction models. The postoperative delirium incidence varied from 11.3 % to 51.6 %. The most frequently used predictors were age and cognitive impairment. The reported areas under the curve or C-statistics were between of 0.74 and 0.91 in the derivation set. The reported AUCs in the external validation set were between 0.54 and 0.90. All the studies had a high risk of bias, mainly owing to poor reporting of the outcome domain and analysis domain; 10 studies were of high concern regarding applicability.

CONCLUSIONS

The current models for predicting postoperative delirium in the ICU after cardiac surgery had a high risk of bias according to the PROBAST. Future studies should focus on improving current prediction models or developing new models with rigorous methodology.

Does the SORG Orthopaedic Research Group Hip Fracture Delirium Algorithm Perform Well on an Independent Intercontinental Cohort of Patients With Hip Fractures Who Are 60 Years or Older?

BACKGROUND

Postoperative delirium in patients aged 60 years or older with hip fractures adversely affects clinical and functional outcomes. The economic cost of delirium is estimated to be as high as USD 25,000 per patient, with a total budgetary impact between USD 6.6 to USD 82.4 billion annually in the United States alone. Forty percent of delirium episodes are preventable, and accurate risk stratification can decrease the incidence and improve clinical outcomes in patients. A previously developed clinical prediction model (the SORG Orthopaedic Research Group hip fracture delirium machine-learning algorithm) is highly accurate on internal validation (in 28,207 patients with hip fractures aged 60 years or older in a US cohort) in identifying at-risk patients, and it can facilitate the best use of preventive interventions; however, it has not been tested in an independent population. For an algorithm to be useful in real life, it must be valid externally, meaning that it must perform well in a patient cohort different from the cohort used to "train" it. With many promising machine-learning prediction models and many promising delirium models, only few have also been externally validated, and even fewer are international validation studies.

QUESTION/PURPOSE

Does the SORG hip fracture delirium algorithm, initially trained on a database from the United States, perform well on external validation in patients aged 60 years or older in Australia and New Zealand?

METHODS

We previously developed a model in 2021 for assessing risk of delirium in hip fracture patients using records of 28,207 patients obtained from the American College of Surgeons National Surgical Quality Improvement Program. Variables included in the original model included age, American Society of Anesthesiologists (ASA) class, functional status (independent or partially or totally dependent for any activities of daily living), preoperative dementia, preoperative delirium, and preoperative need for a mobility aid. To assess whether this model could be applied elsewhere, we used records from an international hip fracture registry. Between June 2017 and December 2018, 6672 patients older than 60 years of age in Australia and New Zealand were treated surgically for a femoral neck, intertrochanteric hip, or subtrochanteric hip fracture and entered into the Australian & New Zealand Hip Fracture Registry. Patients were excluded if they had a pathological hip fracture or septic shock. Of all patients, 6% (402 of 6672) did not meet the inclusion criteria, leaving 94% (6270 of 6672) of patients available for inclusion in this retrospective analysis. Seventy-one percent (4249 of 5986) of patients were aged 80 years or older, after accounting for 5% (284 of 6270) of missing values; 68% (4292 of 6266) were female, after accounting for 0.06% (4 of 6270) of missing values, and 83% (4690 of 5661) of patients were classified as ASA III/IV, after accounting for 10% (609 of 6270) of missing values. Missing data were imputed using the missForest methodology. In total, 39% (2467 of 6270) of patients developed postoperative delirium. The performance of the SORG hip fracture delirium algorithm on the validation cohort was assessed by discrimination, calibration, Brier score, and a decision curve analysis. Discrimination, known as the area under the receiver operating characteristic curves (c-statistic), measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities, a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest.

RESULTS

The SORG hip fracture algorithm, when applied to an external patient cohort, distinguished between patients at low risk and patients at moderate to high risk of developing postoperative delirium. The SORG hip fracture algorithm performed with a c-statistic of 0.74 (95% confidence interval 0.73 to 0.76). The calibration plot showed high accuracy in the lower predicted probabilities (intercept -0.28, slope 0.52) and a Brier score of 0.22 (the null model Brier score was 0.24). The decision curve analysis showed that the model can be beneficial compared with no model or compared with characterizing all patients as at risk for developing delirium.

CONCLUSION

Algorithms developed with machine learning are a potential tool for refining treatment of at-risk patients. If high-risk patients can be reliably identified, resources can be appropriately directed toward their care. Although the current iteration of SORG should not be relied on for patient care, it suggests potential utility in assessing risk. Further assessment in different populations, made easier by international collaborations and standardization of registries, would be useful in the development of universally valid prediction models. The model can be freely accessed at: https://sorg-apps.shinyapps.io/hipfxdelirium/ .

LEVEL OF EVIDENCE

Level III, therapeutic study.

Association of cholinesterase activities and POD in older adult abdominal surgical patients

Background

Postoperative delirium (POD) is a frequent complication after surgery. Older adult patients undergoing abdominal surgery are at higher risk for developing POD. Studies on the association of cholinesterase activities and POD are rare, but leading hypotheses implicate that the cholinergic pathway might play an important role in neuroinflammation and development of POD. The objective of this study was to figure out if there is an association between the development of POD and acetyl- and butyrylcholinesterase (AChE and BuChE) activities in older adult patients undergoing abdominal surgery.

Methods

The investigation was performed with a subpopulation of BioCog study patients. The BioCog project (http://www.biocog.eu) is a prospective multicenter observational study in older adult surgical patients. Patients ≥ 65 years undergoing elective surgery of at least 60 minutes who scored more than 23 points in the Mini-Mental-State-Examination were included. POD was assessed twice a day on seven consecutive days after the surgery, using the test instruments Nursing Delirium Screening Scale (Nu-Desc) and Confusion Assessment Method (CAM and CAM-ICU) and a patient chart review. Pre- and postoperative blood cholinesterase activities were measured with a photometric rapid-point-of-care-testing. The association between cholinesterase activities and POD was analyzed in a subpopulation of abdominal surgical patients using multivariable logistic regression analysis adjusting for confounders.

Results

One hundred twenty-seven patients were included for analysis (mean age 73 years, 59% female). Fifty-two patients (41%) fulfilled the criteria of POD. These patients were significantly older, had a longer time of surgery and anesthesia and achieved higher comorbidity scores compared to patients without POD. After adjusting for age, duration of surgery and charlson comorbity index, we found an association between pre- and postoperative AChE activity (U/gHb) and the development of POD (Odds ratio (OR), [95% confidence interval (CI)], preoperative 0.95 [0.89–1.00], postoperative 0.94 [0.89–1.00]).

Conclusions

We found an association between POD and AChE activity and provided new information considering patients with abdominal surgery. Future analyses should examine course dynamics of postoperative cholinesterase activities in order to clarify interactions between the cholinergic system and pathophysiological mechanisms leading to POD.

Trial registration

ClinicalTrials.gov: NCT02265263.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01826-y.

Reduction of care-relevant risks to older patients during and after acute hospital care (ReduRisk) - study protocol of a cluster randomized efficacy trial in a stepped wedge design

BACKGROUND

Older patients are at an increased risk of hospitalization, negatively affecting their health and quality of life. Such patients also experience a lack of physical activity during their inpatient stay, as well as being at increased risk of delirium and inappropriate prescribing. These risk factors can accumulate, promoting a degree of morbidity and the development of cognitive impairment.

METHODS

Through the ReduRisk-program, patients at risk of functional impairment, immobility, falls, delirium or re-hospitalization shortly after hospital discharge, will be identified via risk-screening. These patients will receive an individually tailored, multicomponent and risk-adjusted prevention program. The trial will compare the effectiveness of the ReduRisk-program against usual care in a stepped-wedge-design, with quarterly cluster randomization of six university hospital departments into intervention and control groups. 612 older adults aged 70 years or more are being recruited. Patients in the intervention cluster (n = 357) will receive the ReduRisk-program, comprising risk-adjusted delirium management, structured mobility training and digitally supported planning of post-inpatient care, including polypharmacy management. This study will evaluate the impact of the ReduRisk-program on the primary outcomes of activities of daily living and mobility, and the secondary outcomes of delirium, cognition, falls, grip strength, health-related quality of life, potentially inappropriate prescribing, health care costs and re-hospitalizations. Assessments will be conducted at inpatient admission (t0), at discharge (t1) and at six months post-discharge (t2). In the six-month period following discharge, a health-economic evaluation will be carried out based on routine health insurance data (t3).

DISCUSSION

Despite the importance of multicomponent, risk-specific approaches to managing older patients, guidelines on their effectiveness are lacking. This trial will seek to provide evidence for the effectiveness of a multicomponent, risk-adjusted prevention program for older patients at risk of functional impairment, immobility, falls, delirium and re-hospitalization. Positive study results would support efforts to improve multicomponent prevention and the management of older patients.

TRIAL REGISTRATION

German Clinical Trials Register, DRKS00025594, date of registration: 09/08/2021.

Development and Validation of a Nomogram for Predicting Postoperative Delirium in Patients With Elderly Hip Fracture Based on Data Collected on Admission

Delirium is a common postoperative complication in elderly hip fracture patients that seriously affects patients’ lives and health, and early delirium risk prediction, and targeted measures can significantly reduce the incidence of delirium. The purpose of this study was to develop and validate a nomogram for the prediction of postoperative delirium (POD) in elderly hip fracture patients. A total of 328 elderly patients with hip fractures enrolled retrospectively in department 1 of our hospital were randomly divided into the training set (n = 230) and the internal validation set (n = 98). The least absolute shrinkage and selection operator (LASSO) regression analysis was used for feature variable selection, and multivariate logistic regression with a backward stepwise method was used to construct a nomogram in the training set. The discrimination efficacy and calibration efficacy of the nomogram were evaluated through the receiver operating characteristic (ROC) curve and calibration curve, respectively. The clinical usefulness was estimated through decision curve analysis (DCA) and clinical impact curve (CIC) analysis. Another validation set from department 2 of our hospital, containing 76 elderly patients with hip fractures, was used for external validation of the nomogram. A total of 43 (13.1%) and 12 (15.8%) patients had POD in department 1 and department 2, respectively. The nomogram was constructed by three predictors, including dementia, chronic obstructive pulmonary disease (COPD), and albumin level. The nomogram showed good discrimination efficacy and calibration efficacy, with the AUC of 0.791 (95% CI, 0.708–0.873), 0.820 (95% CI, 0.676–0.964), and 0.841 (95% CI, 0.717–0.966) in the training set, the internal validation set, and the external validation set, respectively. Both DCA and CIC demonstrated that this nomogram has good clinical usefulness. The nomogram constructed by dementia, COPD, and albumin level can be conveniently used to predict POD in patients with elderly hip fractures.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Review of Postoperative Delirium in Geriatric Patients After Hip Fracture Treatment

Introduction

Postoperative delirium (POD) is a serious complication occurring in 4–53.3% of geriatric patients undergoing surgeries for hip fracture. Incidence of hip fractures is projected to grow 11.9% from 258,000 in 2010 to 289,000 in 2030 based on 1990 to 2010 data. As prevalence of hip fractures is projected to increase, POD is also anticipated to increase.

Signficance

Postoperative delirium remains the most common complication of emergency hip fracture surgery leading to high morbidity and mortality rates despite significant research conducted regarding this topic. This study reviews literature from 1990 to 2021 regarding POD in geriatric hip fracture management.

Results

Potentially modifiable and non-modifiable risk factors for developing POD include, but are not limited to, male gender, older age, multiple comorbidities, specific comorbidities (dementia, cognitive impairment, diabetes, vision impairment, and abnormal blood pressure), low BMI, preoperative malnutrition, low albumin, low hematocrit, blunted preoperative cytokines, emergency surgery, time to admission and surgery, preoperative medical treatment, polypharmacy, delirium-inducing medications, fever, anesthesia time, and sedation depth and type. Although the pathophysiology remains unclear, the leading theories suggest neurotransmitter imbalance, inflammation, and electrolyte or metabolic derangements as the underlying cause of POD. POD is associated with increased length of hospital stay, cost, morbidity, and mortality. Prevention and early recognition are key factors in managing POD. Methods to reduce POD include utilizing interdisciplinary teams, educational programs for healthcare professionals, reducing narcotic use, avoiding delirium-inducing medications, and multimodal pain control.

Conclusion

While POD is a known complication after hip fracture surgery, further exploration in prevention is needed. Early identification of risk factors is imperative to prevent POD in geriatric patients. Early prevention will enhance delivery of health care both pre- and post-operatively leading to the best possible surgical outcome and better quality of life after hip fracture treatment.

ICU delirium burden predicts functional neurologic outcomes

Background

We investigated the effect of delirium burden in mechanically ventilated patients, beginning in the ICU and continuing throughout hospitalization, on functional neurologic outcomes up to 2.5 years following critical illness.

Methods

Prospective cohort study of enrolling 178 consecutive mechanically ventilated adult medical and surgical ICU patients between October 2013 and May 2016. Altogether, patients were assessed daily for delirium 2941days using the Confusion Assessment Method for the ICU (CAM-ICU). Hospitalization delirium burden (DB) was quantified as number of hospital days with delirium divided by total days at risk. Survival status up to 2.5 years and neurologic outcomes using the Glasgow Outcome Scale were recorded at discharge 3, 6, and 12 months post-discharge.

Results

Of 178 patients, 19 (10.7%) were excluded from outcome analyses due to persistent coma. Among the remaining 159, 123 (77.4%) experienced delirium. DB was independently associated with >4-fold increased mortality at 2.5 years following ICU admission (adjusted hazard ratio [aHR], 4.77; 95% CI, 2.10–10.83; P < .001), and worse neurologic outcome at discharge (adjusted odds ratio [aOR], 0.02; 0.01–0.09; P < .001), 3 (aOR, 0.11; 0.04–0.31; P < .001), 6 (aOR, 0.10; 0.04–0.29; P < .001), and 12 months (aOR, 0.19; 0.07–0.52; P = .001). DB in the ICU alone was not associated with mortality (HR, 1.79; 0.93–3.44; P = .082) and predicted neurologic outcome less strongly than entire hospital stay DB. Similarly, the number of delirium days in the ICU and for whole hospitalization were not associated with mortality (HR, 1.00; 0.93–1.08; P = .917 and HR, 0.98; 0.94–1.03, P = .535) nor with neurological outcomes, except for the association between ICU delirium days and neurological outcome at discharge (OR, 0.90; 0.81–0.99, P = .038).

Conclusions

Delirium burden throughout hospitalization independently predicts long term neurologic outcomes and death up to 2.5 years after critical illness, and is more predictive than delirium burden in the ICU alone and number of delirium days.

Automated machine learning-based model predicts postoperative delirium using readily extractable perioperative collected electronic data

Objective

Postoperative delirium (POD) is a common postoperative complication that is relevant to poor outcomes. Therefore, it is critical to find effective methods to identify patients with high risk of POD rapidly. Creating a fully automated score based on an automated machine‐learning algorithm may be a method to predict the incidence of POD quickly.

Materials and methods

This is the secondary analysis of an observational study, including 531 surgical patients who underwent general anesthesia. The least absolute shrinkage and selection operator (LASSO) was used to screen essential features associated with POD. Finally, eight features (age, intraoperative blood loss, anesthesia duration, extubation time, intensive care unit [ICU] admission, mini‐mental state examination score [MMSE], Charlson comorbidity index [CCI], postoperative neutrophil‐to‐lymphocyte ratio [NLR]) were used to established models. Four models, logistic regression, random forest, extreme gradient boosted trees, and support vector machines, were built in a training set (70% of participants) and evaluated in the remaining testing sample (30% of participants). Multivariate logistic regression analysis was used to explore independent risk factors for POD further.

Results

Model 1 (logistic regression model) was found to outperform other classifier models in testing data (area under the curve [AUC] of 80.44%, 95% confidence interval [CI] 72.24%–88.64%) and achieve the lowest Brier Score as well. These variables including age (OR = 1.054, 95%CI: 1.017~1.093), extubation time (OR = 1.027, 95%CI: 1.012~1.044), ICU admission (OR = 2.238, 95%CI: 1.313~3.793), MMSE (OR = 0.929, 95%CI: 0.876~0.984), CCI (OR = 1.197, 95%CI: 1.038~1.384), and postoperative NLR (OR = 1.029, 95%CI: 1.002~1.057) were independent risk factors for POD in this study.

Conclusions

We have built and validated a high‐performing algorithm to demonstrate the extent to which patient risk changes of POD during the perioperative period, thus leading to a rational therapeutic choice.

Study protocol: understanding the pathophysiologic mechanisms underlying delirium in older people undergoing hip fracture surgery

BACKGROUND

Postoperative delirium (POD) is a common complication of older people undergoing hip fracture surgery, which negatively affects clinical- and healthcare-related outcomes. Unfortunately, POD pathophysiology is still largely unknown, despite previous studies showing that neuroinflammation, neuroendocrine dysfunction, increased reactive oxidative stress (ROS), and endothelial dysfunctions may be involved. There is also evidence that many of the pathophysiological mechanisms which are involved in delirium are involved in sarcopenia too. This article describes the protocol of a pilot study to evaluate the feasibility of a larger one that will explore the pathophysiological mechanisms correlating POD with sarcopenia. We will analyse whether various biomarkers reflecting neuroinflammation, ROS, neuroendocrine disorders, and microvasculature lesions will be simultaneously expressed in in the blood, cerebrospinal fluid (CSF), and muscles of patients developing POD.

METHODS

Two centres will be involved in this study, each recruiting a convenient sample of ten older patients with hip fracture. All of them will undergo a baseline Comprehensive Geriatric Assessment, which will be used to construct a Rockwood-based Frailty Index (FI). Blood samples will be collected for each patient on the day of surgery and 1 day before. Additionally, CSF and muscle fragments will be taken and given to a biologist for subsequent analyses. The presence of POD will be assessed in each patient every morning until hospital discharge using the 4AT. Delirium subtypes and severity will be assessed using the Delirium Motor Subtype Scale-4 and the Delirium-O-Meter, respectively. We will also evaluate the patient's functional status at discharge, using the Cumulated Ambulation Score.

DISCUSSION

This study will be the first to correlate biomarkers of blood, CSF, and muscle in older patients with hip fracture.

Early recovery of basic mobility under femoral nerve block after hip fracture surgery - A propensity score matched pilot study

BACKGROUND

Previous studies have shown better pain reduction utilizing femoral nerve block (FNB) in patients who underwent hip fracture surgery. However, few studies have focused on the recovery of physical function after FNB, and most studies excluded patients with dementia. We investigated the association between FNB performed in the operating room and the recovery of physical function after hip fracture surgery, including patients with dementia.

METHODS

A total of 103 patients with a mean age of 87.4 years who underwent hip fracture surgery under spinal anesthesia between July 2015 and December 2017 (46 patients receiving a single injection of FNB and 57 standard care) were enrolled. Patients with FNB versus standard care were matched by a propensity score to adjust for patient characteristics. An anesthesiologist performed FNB with 20ml of 0.2% ropivacaine, and the standard care group received intravenous 1000 mg acetaminophen or 50mg flurbiprofen once after surgery. After matching, 78 patients were analyzed. Our primary outcome was 3-day cumulated ambulation score (CAS, 0-18 points) and secondary outcomes were 1-day CAS on postoperative day 1-3 and length of hospital stay. We also stratified patient groups based on the presence of dementia and fracture type.

RESULTS

Patients undergoing FNB had significantly better 3-day CAS compared to standard care (mean [SD], 8.72 [3.42] vs 7.33 [2.62]; mean difference, 1.38 [95%CI; 0.03 - 2.74]; p = 0.048) and 1-day CAS on postoperative day two (mean [SD], 3.10 [1.39] vs 2.56 [0.94]; mean difference, 0.54 [0.01 - 1.07]; p = 0.049). Length of hospital stay did not significantly differ among the two groups (p = 0.65). Larger positive effect was likely to be seen for patients with a femoral neck fractures and for those without dementia.

CONCLUSIONS

Patients who underwent surgery with spinal anesthesia plus FNB had better ambulatory status early after hip fracture surgery compared to patients not offered FNB. The beneficial association between FNB and ambulatory status was likely to be observed especially in patients with femoral neck fracture and without dementia.

Effects of Intraoperative Dexmedetomidine Infusion on Postoperative Delirium in Elderly Patients Undergoing Total Hip Arthroplasty

Objective

To investigate the effects of dexmedetomidine on postoperative delirium in elderly patients undergoing total hip arthroplasty.

Methods

A total of 100 patients, 42 male and 58 female, ages 60 to 85 years, American Society of Anesthesiologists grade I or II, who were undergoing total hip arthroplasty were randomly divided into 2 groups: a dexmedetomidine group (group D; n = 50) and a control group (group C; n = 50). Group D patients were infused with 0.3 μg · kg−1 · h−1 of dexmedetomidine from 5 minutes prior to anesthesia induction until the end of surgery. Group C patients received an equal volume of saline. Heart rate and mean arterial pressure (MAP) were recorded before anesthesia induction (T0), 1 minute before extubation (T1), and 30 minutes after extubation (T2). The Visual Analog Score (VAS) at 1, 2, and 3 days after surgery, the incidence and duration of postoperative delirium, and the length of hospital stay were recorded. Adverse reactions, such as nausea, vomiting, and lethargy, were also recorded.

Results

The Visual Analog Scores in the 2 groups were similar. In group D, there was no significant difference in heart rate (P = 0.232) and MAP (P = 0.056) between T0 and T1. However, in group C, heart rate significantly increased by 15.3 bpm (P = 0.000) and MAP significantly increased by 10.7 mmHg (P = 0.001) at T1 compared with those at T0. The incidence of postoperative delirium in group D (10%) was significantly lower than that in group C (26%; P = 0.037). The duration of delirium in group D (1.3 ± 0.6 days) was shorter than that in group C (3.0 ± 0.5 days; P = 0.000). The length of hospital stay in group D (13.2 ± 0.9 days) was shorter than that in group C (16.1 ± 0.7 days; P = 0.000). No significant differences were observed in adverse effects between the 2 groups.

Conclusion

Intravenous infusion of dexmedetomidine can not only reduce the incidence and duration of postoperative delirium, but also shorten the length of hospital stay in elderly patients undergoing total hip arthroplasty.

Frailty, post-operative delirium and functional status at discharge in patients with hip fracture

OBJECTIVE

To explore the effect of frailty, alone and in combination with post-operative delirium (POD), on the risk of poor function at discharge in patients with hip fracture (HF).

METHODS

This is a prospective cohort study of patients with HF admitted to an Orthogeriatric Unit (OGU) between October 1, 2011 and March 15, 2019. POD was assessed using the 4AT and the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5-edition criteria. A 22-items Frailty Index (FI) was created using the data collected on admission. The outcome measure was the Cumulated Ambulation Score (CAS) score at discharge. A log-binomial regression model was used to assess the effect of frailty and POD on CAS.

RESULTS

A total of 988 patients (median age = 84.9 years, Interquartile range = 80.6-89.2) were included: 360 patients (36.4%) were frail and 411 (42%) developed POD. Poor functional status at discharge (CAS score ≤2) was more common in frail than non-frail patients (68.3% vs. 53.8%, p < 0.001) In a regression adjusted for confounders, frailty alone (Relative Risk, RR = 1.33, 95% Confidence Intervals, CI = 1.14-1.55) and POD alone (RR 1.38, 95% CI = 1.2-1.59) were associated with poor functional status at discharge; when combined, frailty and POD had an interaction, yielding a mild increase in the risk of poor outcome (RR 1.47, 95% CI = 1.28-1.69).

CONCLUSIONS

In older patients undergoing HF surgery, frailty, POD and their combination, are associated with poor functional status at discharge.

Orthogeriatric co-management for the care of older subjects with hip fracture: recommendations from an Italian intersociety consensus

BACKGROUND

Health outcomes of older subjects with hip fracture (HF) may be negatively influenced by multiple comorbidities and frailty. An integrated multidisciplinary approach (i.e. the orthogeriatric model) is, therefore, highly recommended, but its implementation in clinical practice suffers from the lack of shared management protocols and poor awareness of the problem. The present consensus document has been implemented to address these issues.

AIM

To develop evidence-based recommendations for the orthogeriatric co-management of older subjects with HF.

METHODS

A 20-member Expert Task Force of geriatricians, orthopaedics, anaesthesiologists, physiatrists, physiotherapists and general practitioners was established to develop evidence-based recommendations for the pre-, peri-, intra- and postoperative care of older in-patients (≥ 65 years) with HF. A modified Delphi approach was used to achieve consensus, and the U.S. Preventive Services Task Force system was used to rate the strength of recommendations and the quality of evidence.

RESULTS

A total of 120 recommendations were proposed, covering 32 clinical topics and concerning preoperative evaluation (11 topics), perioperative (8 topics) and intraoperative (3 topics) management, and postoperative care (10 topics).

CONCLUSION

These recommendations should ease and promote the multidisciplinary management of older subjects with HF by integrating the expertise of different specialists. By providing a convenient list of topics of interest, they might assist in identifying unmet needs and research priorities.

Urinary albumin creatinine ratio associated with postoperative delirium in elderly patients undergoing elective non-cardiac surgery: A prospective observational study

Introduction

The blood‐brain barrier (BBB) disruption contributes to postoperative delirium, but cost‐effective and non‐invasive assessment of its permeability is not practicable in the clinical settings. Urine albumin to creatinine ratio (UACR), reflecting systemic vascular endothelial dysfunction, may be a prognostic and predictive factor associated with postoperative delirium. The aim was to analyze the relationship between UACR and postoperative delirium in elderly patients undergoing elective non‐cardiac surgery.

Materials and methods

Through stratified random sampling, a cohort of 408 individuals aged 60 years and older scheduled for elective non‐cardiac surgery were included between February and August 2019 in the single‐center, prospective, observational study. The presence of delirium was assessed using the Confusion Assessment Method (CAM) or Confusion Assessment Method for the ICU (CAM‐ICU) on the day of surgery, at 2 h after the surgery ending time and on the first 3 consecutive days with repeated twice‐daily, with at least 6‐h intervals between assessments. Urine samples were collected on one day before surgery, and 1st day and 3rd day after surgery. The primary outcome was the presence of postoperative delirium, and association of the level of UACR with postoperative delirium was evaluated with unadjusted/adjusted analyses and multivariable logistic regression.

Results

Postoperative delirium was observed in 26.75% (107 of 400) of patients within 3 days post‐surgery. UACR‐Pre (OR, 1.30; 95% CI, 1.14–1.49, p < 0.001), UACR‐POD1 (OR, 1.20; 95% CI, 1.13–1.27, p < 0.001), and UACR‐POD3 (OR, 1.14; 95% CI, 1.08–1.20, p < 0.001) between the delirium and non‐delirium groups show a significant difference, even after adjusting for age, education levels, and other factors.

Conclusion

As the marker of endothelial dysfunction, the high perioperative UACR value may be linked to the postoperative delirium in elderly patients undergoing elective non‐cardiac surgery.

Delirium symptoms duration and mortality in SARS-COV2 elderly: results of a multicenter retrospective cohort study

Background

Since the occurrence of the SARS-COV2 pandemic, there has been an increasing interest in investigating the epidemiology of delirium. Delirium is frequent in SARS-COV2 patients and it is associated with increased mortality; however, no information is available on the association between delirium duration in SARS-COV2 patients and related outcomes.

Aims

The aim of this study is to investigate the association between the duration of delirium symptoms and in-hospital mortality in older patients with SARS-COV2 infection.

Methods

Retrospective cohort study of patients 65 years of age and older with SARS-CoV 2 infection admitted to two acute geriatric wards and one rehabilitation ward. Delirium symptoms duration was assessed retrospectively with a chart-based validated method. In-hospital mortality was ascertained via medical records.

Results

A total of 241 patients were included. The prevalence of delirium on admission was 16%. The median number of days with delirium symptoms was 4 (IQR 2–6.5) vs. 0 (IQR 0–2) in patients with and without delirium on admission. In the multivariable Cox regression model, each day with a delirium symptom in a patient with the same length of stay was associated with a 10% increase in in-hospital mortality (Hazard ratio 1.1, 95% Confidence interval 1.01–1.2; p = 0.03). Other variables associated with increased risk of in-hospital death were age, comorbidity, CPAP, CRP levels and total number of drugs on admission.

Conclusions

The study supports the necessity to establish protocols for the monitoring and management of delirium during emergency conditions to allow an appropriate care for older patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40520-021-01899-8.

Effect of electroencephalogram-guided anaesthesia administration on 1 yr mortality: 1 yr follow-up of a randomised clinical trial

BACKGROUND

Intraoperative EEG suppression duration has been associated with postoperative delirium and mortality. In a clinical trial testing anaesthesia titration to avoid EEG suppression, the intervention did not decrease the incidence of postoperative delirium, but was associated with reduced 30 day mortality. The present study evaluated whether the EEG-guided anaesthesia intervention continued to be associated with reduced 1 yr mortality.

METHODS

This manuscript reports 1 yr follow-up of patients from a single-centre RCT, including a post-hoc secondary outcome (1 yr mortality) in addition to pre-specified secondary outcomes. The trial included patients aged 60 yr or older undergoing surgery with general anaesthesia between January 2015 and May 2018. Patients were randomised to receive EEG-guided anaesthesia or usual care. The previously reported primary outcome was postoperative delirium. The outcome of the current study was all-cause 1 yr mortality.

RESULTS

Of the 1232 patients enrolled, 614 patients were randomised to EEG-guided anaesthesia and 618 patients to usual care. One year mortality was 57/591 (9.6%) in the guided group and 62/601 (10.3%) in the usual-care group. No significant difference in mortality was observed (adjusted absolute risk difference, -0.7%; 99.5% confidence interval, -5.8% to 4.3%; P=0.68).

CONCLUSIONS

An EEG-guided anaesthesia intervention aiming to decrease duration of EEG suppression during surgery did not significantly decrease 1 yr mortality. These findings, in the context of other studies, do not provide supportive evidence for EEG-guided anaesthesia to prevent intermediate term postoperative death.

CLINICAL TRIAL REGISTRATION

NCT02241655.

A core outcome set for studies evaluating interventions to prevent and/or treat delirium for adults requiring an acute care hospital admission: an international key stakeholder informed consensus study

BACKGROUND

Trials of interventions to prevent or treat delirium in adults in an acute hospital setting report heterogeneous outcomes. Our objective was to develop international consensus among key stakeholders for a core outcome set (COS) for future trials of interventions to prevent and/or treat delirium in adults with an acute care hospital admission and not admitted to an intensive care unit.

METHODS

A rigorous COS development process was used including a systematic review, qualitative interviews, modified Delphi consensus process, and in-person consensus using nominal group technique (registration http://www.comet - initiative.org/studies/details/796 ). Participants in qualitative interviews were delirium survivors or family members. Participants in consensus methods comprised international representatives from three stakeholder groups: researchers, clinicians, and delirium survivors and family members.

RESULTS

Item generation identified 8 delirium-specific outcomes and 71 other outcomes from 183 studies, and 30 outcomes from 18 qualitative interviews, including 2 that were not extracted from the systematic review. De-duplication of outcomes and formal consensus processes involving 110 experts including researchers (N = 32), clinicians (N = 63), and delirium survivors and family members (N = 15) resulted in a COS comprising 6 outcomes: delirium occurrence and reoccurrence, delirium severity, delirium duration, cognition, emotional distress, and health-related quality of life. Study limitations included exclusion of non-English studies and stakeholders and small representation of delirium survivors/family at the in-person consensus meeting.

CONCLUSIONS

This COS, endorsed by the American and Australian Delirium Societies and European Delirium Association, is recommended for future clinical trials evaluating delirium prevention or treatment interventions in adults presenting to an acute care hospital and not admitted to an intensive care unit.

A bibliometric analysis of orthogeriatric care: top 50 articles

Background

Population is ageing and orthogeriatric care is an emerging research topic.

Purpose

This bibliometric review aims to provide an overview, to investigate the status and trends in research in the field of orthogeriatric care of the most influential literature.

Methods

From the Core Collection databases in the Thomson Reuters Web of Knowledge, the most influential original articles with reference to orthogeriatric care were identified in December 2020 using a multistep approach. A total of 50 articles were included and analysed in this bibliometric review.

Results

The 50 most cited articles were published between 1983 and 2017. The number of total citations per article ranged from 34 to 704 citations (mean citations per article: n = 93). Articles were published in 34 different journals between 1983 and 2017. In the majority of publications, geriatricians (62%) accounted for the first authorship, followed by others (20%) and (orthopaedic) surgeons (18%). Articles mostly originated from Europe (76%), followed by Asia–pacific (16%) and Northern America (8%). Key countries (UK, Sweden, and Spain) and key topic (hip fracture) are key drivers in the orthogeriatric research. The majority of articles reported about therapeutic studies (62%).

Conclusion

This bibliometric review acknowledges recent research. Orthogeriatric care is an emerging research topic in which surgeons have a potential to contribute and other topics such as intraoperative procedures, fractures other than hip fractures or elective surgery are related topics with the potential for widening the field to research.

Predictors and Sequelae of Postoperative Delirium in a Geriatric Patient Population With Hip Fracture

Introduction:

Postoperative delirium is common for patients with hip fracture. Predictors of postoperative delirium and its association with preexisting dementia and adverse postoperative outcomes in a geriatric hip fracture population were assessed.

Methods:

Patients with hip fracture aged 60 years and older were identified in the 2016 and 2017 National Surgical Quality Improvement Program Procedure Targeted Databases. Independent risk factors of postoperative delirium were identified. Associations with mortality, readmission, and revision surgery were evaluated using moderation and mediation analysis.

Results:

Of 18,754 patients with hip fracture, 30.2% had preoperative dementia, 18.8% had postoperative delirium, and 8.3% had both preoperative dementia and postoperative delirium. Independent predictors of postoperative delirium were as follows: older age, male sex, higher American Society of Anesthesiologists score, dependent functional status, nongeneral anesthesia, preoperative diabetes, bleeding disorder, and preoperative dementia. Preoperative dementia and postoperative delirium each had an independent correlation with 30-day mortality (odds ratios = 2.06 and 1.92, respectively, with P < 0.001 for both). However, when both were present, those with preoperative dementia and postoperative delirium had an even higher odds of mortality based on moderation analysis (odds ratio = 2.25, P < 0.001). Readmissions and reoperations were significantly correlated with postoperative delirium, but not with preoperative dementia. The combination of preoperative dementia and postoperative delirium, however, did have compounding effects. Furthermore, a significant proportion of the total effect of preoperative dementia on mortality and readmission was accounted for by the development of postoperative delirium based on mediation analysis (medeff: 7%, P < 0.001 and medeff: 35%, P < 0.001).

Discussion:

Postoperative delirium is a potentially preventable postoperative adverse outcome that was seen in 18.8% of 18,754 patients with hip fracture. Those with preoperative dementia seem to be a particularly at-risk subpopulation. Quality improvement initiatives to minimize postoperative delirium in this hip fracture population should be considered and optimized.

Delirium: A Marker of Vulnerability in Older People

Delirium is an acute neuropsychiatric syndrome and one of the most common presenting symptoms of acute medical illnesses in older people. Delirium can be triggered by a single cause, but in most cases, it is multifactorial as it depends on the interaction between predisposing and precipitating factors. Delirium is highly prevalent in older patients across various settings of care and correlates with an increased risk of adverse clinical outcomes. Several pathophysiological mechanisms may contribute to its onset, including neurotransmitter imbalance, neuroinflammation, altered brain metabolism, and impaired neuronal network connectivity. Several screening and diagnostic tools for delirium exist, but they are unfortunately underutilized. Additionally, the diagnosis of delirium superimposed on dementia poses a formidable challenge - especially if dementia is severe. Non-pharmacological approaches for the prevention and multidomain interventions for the treatment of delirium are recommended, given that there is currently no robust evidence of drugs that can prevent or resolve delirium. This article aims to review the current understanding about delirium in older people. To achieve this goal, we will describe the epidemiology and outcomes of the syndrome, the pathophysiological mechanisms that are supposed to be involved, the most commonly used tools for screening and diagnosis, and prevention strategies and treatments recommended. This review is intended as a brief guide for clinicians in hospital wards to improve their knowledge and practice. At the end of the article, we propose an approach to improve the quality of care provided to older patients throughout a systematic detection of delirium.

The risk factors of postoperative delirium in patients with hip fracture: implication for clinical management

Background

Delirium is a common complication of hip surgery patients. It is necessary to investigate the epidemiological characteristics and related risk factors of delirium after hip fracture surgery, to provide evidence supports for the prevention and management of delirium.

Methods

Hip fracture patients admitted to our hospital for surgical treatment from March 2018 to March 2020 were identified as participants. The characteristics and laboratory examinations in patients with and without postoperative delirium were compared and analyzed. Logistic regression analyses were conducted to ascertain the independent risk factors, and the area under the curve (AUC) were calculated to analyze the predictive value.

Results

A total of 568 postoperative patients with hip fracture were included, the incidence of delirium in postoperative patients with hip fracture was 14.44 %. The preoperative albumin (OR 4.382, 2.501 ~ 5.538), history of delirium (OR 2.197, 1.094 ~ 3.253), TSH (OR1.245, 1.077 ~ 1.638), the resting score on the first postoperative day (OR1.235, 0.944 ~ 1.506) and age(OR1.185, 0.065 ~ 1.814) were the independent risk factors for the postoperative delirium in patients with hip fracture(all p < 0.05). The AUC of albumin, history of delirium, TSH, the resting score on the first postoperative day and age were 0.794, 0.754, 0.746, 0.721 and 0.689 respectively.

Conclusions

The incidence of delirium in postoperative patients with hip fracture is rather high, especially for patients with old age and history of delirium. Monitoring albumin, TSH and resting score may be beneficial to the management of postoperative delirium.

Delirium after Deep Brain Stimulation in Parkinson's Disease

Deep brain stimulation is a primary treatment method that improves motor and motor complications in patients with advanced Parkinson's disease. Delirium is a common and serious complication following deep brain stimulation. However, the clinical attention toward this complication remains insufficient. Advanced age, cognitive decline, and the severity of the disease may all be risk factors for delirium. The presence of delirium may also affect cognitive function and disease prognosis. Neurotransmitters such as acetylcholine and dopamine may be involved in the occurrence of delirium. Furthermore, inflammation, the effects of microlesioning of local nuclei, and brain atrophy may also play roles in the onset of delirium. Nonpharmacological therapy appears to be the primary treatment for postoperative delirium in Parkinson's disease. The current article reviews the pathogenesis, epidemiology, prognosis, and treatment of delirium following deep brain stimulation in Parkinson's disease to help clinicians better understand this common complication and to prevent, identify, and treat it as soon as possible, as well as to provide more accurate treatment for patients.

Preoperative Prognostic Nutritional Index Value is Related to Postoperative Delirium in Elderly Patients After Noncardiac Surgery: A Retrospective Cohort Study

Purpose

Malnutrition has been considered as a risk factor for postoperative delirium (POD). The Prognostic Nutritional Index (PNI) is a validated tool for assessing nutritional status. This study aimed to investigate the association between preoperative PNI values and the occurrence of POD in elderly surgical patients.

Methods

The retrospective cohort study included 361 elderly individuals who underwent noncardiac surgery between 2018 and 2019. Perioperative data were collected from the patients’ medical records. PNI was used to evaluate preoperative nutritional status. The primary outcome was the occurrence of POD. Univariate and multivariate logistic regression analyses were used to identify key factors associated with POD and assess the relationship between PNI values and the occurrence of POD. Receiver operating characteristic (ROC) curve analysis was used to assess the predictive value of PNI for POD.

Results

Seventy-two (19.9%) individuals developed postoperative delirium after surgery. Compared with patients of normal nutrition status (PNI ≥ 50), mild malnutrition (PNI 45–50) did not increase the risk of POD, while patients with moderate to severe malnutrition (PNI 40–45) (odds ratio [OR], 2.92; 95% confidence interval [CI], 1.31–6.50) and serious malnutrition (PNI < 40) (OR, 3.15; 95% CI, 1.12–8.83) were more likely to develop POD. The cut-off value of PNI was 46.05 by ROC curve analysis, the area under the curve (AUC) was 0.69 (95% CI 0.62–0.77).

Conclusion

Preoperative PNI value is related to postoperative delirium in elderly patients after noncardiac surgery.

Antipsychotics and Lorazepam During Delirium: Are We Harming Older Patients? A Real-Life Data Study

BACKGROUND

Delirium affects approximately one out of three older hospitalized patients and is associated with poor clinical outcomes. Approaches used to manage delirium consist of non-pharmacological and pharmacological interventions. Antipsychotics and lorazepam are commonly used to treat symptoms of delirium, but conflicting data exist on the effect of these drugs on the outcomes of delirium.

OBJECTIVE

The aim of this study was to investigate whether the use of antipsychotics, with or without lorazepam, increases the risk of prolonged hospital stay, post-discharge institutionalization, and in-hospital mortality in older patients with delirium.

METHODS

In this retrospective chart review study, we included acutely ill patients aged ≥ 65 years who were admitted to a geriatric ward and diagnosed with delirium. Patients were stratified into three groups based on whether or not they received antipsychotics and lorazepam to manage delirium: (0) no antipsychotics; (1) antipsychotics only; and (2) antipsychotics plus lorazepam. Length of hospital stay (LOS) and frequencies of post-discharge institutionalization and in-hospital mortality were compared.

RESULTS

In total, 212 patients with delirium were included (mean age 81.9 ± 5.6 years); 40 did not receive antipsychotics (18.9%), 123 received antipsychotics only (58.0%) and 49 received antipsychotics and lorazepam (23.1%). There was a trend to a longer LOS in patients who received both antipsychotics and lorazepam (median LOS group 0 = 8.0 days, group 1 = 10.0 days, and group 2 = 12.0 days). Furthermore, trends to a higher incidence of post-discharge institutionalization and in-hospital mortality were observed in patients who received both treatments (institutionalization group 0 = 45.0%, group 1 = 59.3%, group 2 = 81.6%; and in-hospital mortality group 0 = 7.5%, group 1 = 10.6%, group 2 = 16.3%).

CONCLUSION

The use of antipsychotics, with or without lorazepam, during delirium is associated with increased risks of poor outcomes. These findings suggest that clinicians should be cautious about routine prescribing of these drugs to older patients with delirium. Further investigation is needed to clarify this association.

Validation of the 3-minute diagnostic interview for CAM-defined Delirium in Chinese older adults

Delirium is a common complication among older adults, but it is often unrecognized in routine practice. The 3-Minute Diagnostic Interview for CAM-defined Delirium (3D-CAM) was developed to identify delirium in the general unit. This prospective diagnostic study was conducted to validate the accuracy of the 3D-CAM Chinese version among older adults in the general units. A total of 204 hospitalized older adults from a geriatric hospital were enrolled in the study, of whom 54 were identified as positive for delirium. The sensitivity and specificity of the 3D-CAM Chinese version were 94% and 97%, respectively. The median duration of assessment using the 3D-CAM was about 3 minutes. The 3D-CAM had highly acceptable sensitivity and specificity when it was used by nurse researchers among Chinese older adults.

Prevalence, Predictors, and Early Outcomes of Post-operative Delirium in Patients With Type A Aortic Dissection During Intensive Care Unit Stay

Objectives: The aim of this study was to investigate the prevalence and explore the predictors and early outcomes of post-operative delirium (POD) in patients with type A aortic dissection (AAD) during intensive care unit (ICU) stays.

Methods: We retrospectively reviewed the records of 301 patients with AAD who underwent surgical treatment in our institution from January 2017 to December 2018.

Results: Delirium developed in 73 patients (24.25%) during the ICU stay. Patients with lower estimated glomerular filtration rates [odds ratio (OR) 0.84, 95% CI 0.74–0.94, p = 0.003], post-operative midazolam use (OR 2.37, 95% CI 1.33–4.23, p = 0.004), and post-operative morphine use (OR 1.87, 95% CI 1.07–3.29, p = 0.029) were more susceptible to developing POD. Patients who developed POD had a longer ICU stay (11.52 vs. 7.22 days, p < 0.001) and hospital stay (23.99 vs. 18.91, p = 0.007) with higher hospitalization costs (48.82 vs. 37.66 thousand dollars, p < 0.001) than those without POD. The in-hospital mortality rate was higher in the delirium group, but the difference was not significant (6.85 vs. 4.82%, p = 0.502).

Conclusions: The incidence of POD in patients with AAD was high and was associated with renal dysfunction and the use of midazolam and morphine. POD was associated with poor early outcomes, suggesting the importance of early screening, such as for renal dysfunction, and prevention by using sedation scales to minimize the use of midazolam and morphine in these patients.