A polysomnography study examining the association between sleep and postoperative delirium in older hospitalized cardiac surgical patients

Effect of desflurane maintenance on postoperative sleep quality in patients undergoing elective breast surgery: A non-inferiority randomized controlled trail

BACKGROUND

Postoperative sleep disturbance (PSD) is prevalent in perioperative patients，and has significant impact on postoperative recovery and prognosis. The aim of this study was to investigate the effect of desflurane maintenance on postoperative sleep quality, in order to optimize patients' perioperative sleep management.

METHOD

A total of 118 patients undergoing elective breast surgery were randomized to receive either desflurane-based volatile anesthesia (desflurane group) or propofol-based total intravenous anesthesia (propofol group) for anesthesia maintenance. The primary outcome was the quality of sleep, which was assessed by the Pittsburgh Sleep Quality Index (PSQI) on 3 days after operation (POD3). Secondary outcomes were PSQI on postoperative day 7 (POD7) and 30 (POD30), and postoperative anxiety, depression, and pain score, as well as objective sleep parameters including total sleep time (TST), WASO (Wakefulness after sleep onset), REM (Rapid eye movement) and NREM (Non-rapid Eye Movement) measured by Fitbit Charge 2TM during the initial 3 postoperative days.

RESULTS

The global PSQI scores on POD3 in the desflurane group was non-inferior to that in the propofol group [mean (SD) 8.47 (3.46) vs. 7.65 (3.16); mean difference (95 % CI) 0.82 (-0.43, 2.07); p < 0.001 for non-inferiority]. There were no significant differences in PSQI scores on POD3 and POD7. In addition, the score of anxiety, depression, and pain on the 3rd, 7th, and 30th day after surgery have no significant differences between the propofol and the desflurane group, respectively. The postoperative NREM was higher in the desflurane group than that in the propofol group.

CONCLUSION

The effects of desflurane-based volatile anesthesia maintenance on postoperative sleep quality is not inferior to that of propofol-based total intravenous anesthesia, and these two drugs may have different effects on the sleep structure.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04805775.

Association Between Preoperative Long-Term Poor Sleep Quality and Postoperative Delirium in Elderly Patients Undergoing Cardiac Surgery: A Multi-Center Observational Study

BACKGROUND

Delirium is a common complication in elderly patients after cardiac surgery, and sleep disorders have been suggested as a potential risk factor. However, few studies have explored the link between long-term preoperative poor sleep quality and postoperative delirium (POD) in this population. This study aimed to investigate the association between preoperative sleep quality and POD in elderly cardiac surgery patients.

METHODS

The study enrolled 194 patients aged 60 years or older who underwent cardiac surgery. The Pittsburgh Sleep Quality Index (PSQI) objectively assessed preoperative sleep quality, while the Confusion Assessment Method screened for POD. The measurable outcomes encompassed the identification of risk factors associated with POD, while the secondary outcomes focused on factors influencing levels of consciousness. The statistical analysis is logistic regression analysis.

RESULTS

Patients with POD had a higher prevalence of preoperative sleep disorders and higher PSQI scores than those without delirium (12.9 ± 5.1 vs 7.8 ± 3.4, P = .007). Logistic regression analysis demonstrated that the number of months with high PSQI scores and age were significantly associated with POD. The predictive ability of the number of months with high PSQI scores for POD was .762 (95% CI: .671-.854). Multivariate linear regression analysis revealed that preoperative sleep disorder was a significant predictor of exacerbation of POD (P < .05).

CONCLUSION

This study suggests that long-term poor preoperative sleep quality, as assessed by the PSQI, is associated with an increased risk of POD in elderly patients undergoing cardiac surgery.

Effects of Intranasal Insulin Pretreatment on Preoperative Sleep Quality and Postoperative Delirium in Patients Undergoing Valve Replacement for Rheumatic Heart Disease

Background

Postoperative delirium (POD) is a common neurological complication associated with valve replacement. Preoperative sleep disturbance is a risk factor for POD development, and nasal insulin modulates the sleep-wake cycle. This study investigated the beneficial effects of intranasal insulin pretreatment on preoperative sleep quality and reducing POD in patients undergoing valve replacement for rheumatic heart disease.

Patients and Methods

This prospective, single-center, randomized controlled trial (RCT) included 76 adult patients aged 18-65 years undergoing valve surgery with cardiopulmonary bypass who were randomly allocated to receive intranasal insulin or normal saline interventions two days before surgery. POD incidence was on postoperative days 1 (T3), 2 (T4), and 3 (T5). Before the first intervention (T0), 1 d before surgery (T1), and before anesthesia on the day of surgery (T2), sleep quality was assessed and serum cortisol concentrations were measured. At T1 and T2, sleep quality related indicators monitored by sleep monitoring watches from the previous night were recorded.

Results

Compared with the normal saline group, 3 days after surgery, the insulin group showed a significantly reduced incidence of POD; significantly increased deep sleep, REM sleep, deep sleep continuity, and total sleep quality scores at T1 and T2; and significantly reduced serum cortisol concentration, PSQI scale, light sleep ratio, and wakefulness at T1 and T2.

Conclusion

The administration of 20 U of intranasal insulin twice daily, from 2 days preoperatively until 10 minutes preanesthesia on the day of surgery, can improved preoperative sleep quality significantly and reduced POD incidence in patients with rheumatic heart disease undergoing valve replacement.

Clinical Trial Registration

This study was registered with the Chinese Clinical Trial Registry (www.chictr.org.cn, with the unique identifier ChiCTR2100048515; July 9, 2021).

Sleep and circadian biomarkers of postoperative delirium (SLEEP-POD): protocol for a prospective and observational cohort study

INTRODUCTION

Surgical patients over 70 experience postoperative delirium (POD) complications in up to 50% of procedures. Sleep/circadian disruption has emerged as a potential risk factor for POD in epidemiological studies. This protocol presents a single-site, prospective observational study designed to examine the relationship between sleep/circadian regulation and POD and how this association could be moderated or mediated by Alzheimer's disease (AD) pathology and genetic risk for AD.

METHODS AND ANALYSIS

Study staff members will screen for eligible patients (age ≥70) seeking joint replacement or spinal surgery at Massachusetts General Hospital (MGH). At the inclusion visit, patients will be asked a series of questionnaires related to sleep and cognition, conduct a four-lead ECG recording and be fitted for an actigraphy watch to wear for 7 days before surgery. Blood samples will be collected preoperatively and postoperatively and will be used to gather information about AD variant genes (APOE-ε4) and AD-related pathology (total and phosphorylated tau). Confusion Assessment Method-Scale and Montreal Cognitive Assessment will be completed twice daily for 3 days after surgery. Seven-day actigraphy assessments and Patient-Reported Outcomes Measurement Information System questionnaires will be performed 1, 3 and 12 months after surgery. Relevant patient clinical data will be monitored and recorded throughout the study.

ETHICS AND DISSEMINATION

This study is approved by the IRB at MGH, Boston, and it is registered with the US National Institutes of Health on ClinicalTrials.gov (NCT06052397). Plans for dissemination include conference presentations at a variety of scientific institutions. Results from this study are intended to be published in peer-reviewed journals. Relevant updates will be made available on ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

NCT06052397.

Association Between Preoperative Sleep Disturbance and Postoperative Delirium in Elderly: A Retrospective Cohort Study

Purpose

Postoperative sleep disturbance, characterized by diminished postoperative sleep quality, is a risk factor for postoperative delirium (POD); however, the association between pre-existing sleep disturbance and POD remains unclear. This study aimed to evaluate the association between preoperative sleep disturbance and POD in elderly patients after non-cardiac surgery.

Patients and methods

This retrospective cohort study was conducted at a single center and enrolled 489 elderly patients who underwent surgery between May 1, 2020, and March 31, 2021. Patients were divided into the sleep disorder (SD) and non-sleep disorder (NSD) groups according to the occurrence of one or more symptoms of insomnia within one month or sleep- Numerical Rating Scale (NRS)≥6 before surgery. The primary outcome was the incidence of POD. Propensity score matching analysis was performed between the two groups. Multiple logistic regression analysis was performed to identify the risk factors for POD.

Results

In both the unmatched cohort (16.0% vs 6.7%, P=0.003) and the matched cohort (17.0% vs 6.2%, P=0.023), the incidence of POD was higher in the SD group than in the NSD group. In addition, the postoperative sleep quality and the VAS score at postoperative 24 h were significantly lower in the SD group than in the NSD group. Multivariate logistic regression analysis indicated that age (Odds Ratio, 1.13 [95% CI: 1.04-1.23], P=0.003) and preoperative sleep disturbance (Odds Ratio, 3.03 [95% CI: 1.09-9.52], P=0.034) were independent risk factors for the development of POD.

Conclusion

The incidence of POD was higher in patients with pre-existing sleep disturbance than those without it. Whether improving sleep quality for preoperative sleep disturbance may help prevent POD remains to be determined.

Impact of Preoperative Sleep Disturbances on Postoperative Delirium in Patients with Intracranial Tumors: A Prospective, Observational, Cohort Study

Background

Postoperative delirium (POD) is prevalent in craniotomy patients and is associated with high mortality. Sleep disturbances are receiving increasing attention from clinicians as associated risk factors for postoperative complications. This study aimed to determine the impact of preoperative sleep disturbances on POD in craniotomy patients.

Methods

We recruited 130 patients undergoing elective craniotomy for intracranial tumors between May 1st and December 30th, 2022. Preoperative subjective sleep disturbances were assessed using the Pittsburgh Sleep Quality Index on the day of admission. We also measured objective perioperative sleep patterns using a dedicated sleep monitoring device 3 days before and 3 days after the surgery. POD was assessed twice daily using the Confusion Assessment Model for the Intensive Care Unit within the first week after craniotomy.

Results

Preoperative sleep disturbances were diagnosed in 49% of the study patients, and POD was diagnosed in 22% of all the study patients. Sleep disturbances were an independent risk factor for POD (OR: 2.709, 95% CI: 1.020-7.192, P = 0.045). Other risk factors for POD were age (OR: 3.038, 95% CI: 1.195-7.719, P = 0.020) and the duration of urinary catheterization (OR: 1.246, 95% CI: 1.025-1.513, P = 0.027). Perioperative sleep patterns (including sleep latency, deep sleep duration, frequency of awakenings, apnea-hypopnea index, and sleep efficiency) were significantly associated with POD.

Conclusion

This study demonstrated that preoperative sleep disturbances predispose patients undergoing craniotomy to POD, also inferred a correlation between perioperative sleep patterns and POD. The targeted screening and intervention specifically for sleep disturbances during the perioperative period are immensely required.

Effects of dexmedetomidine dosage on the short-term cognitive function of elderly patients undergoing cardiac surgery

BACKGROUND

This study aimed to investigate the effects of perioperative dexmedetomidine (DEX) infusion rates on the postoperative short-term cognitive function.

METHODS

A total of 88 patients aged ≥ 60 years who underwent cardiac surgery from January 2022 to November 2022 at the First Affiliated Hospital of The University of Science and Technology of China (USTC) were included. Based on a single-center pilot analysis, patients were divided into two groups according to the rate of intraoperative DEX infusion, which started after tracheal intubation and continued until 1 h before extubation in the cardiac surgery intensive care unit. In Group L (n = 44), the infusion rate was 0.1-0.5 µg/kg/h (low-dose group), whereas in Group H (n = 44), the infusion rate was 0.5-0.9 µg/kg/h (high-dose group). Clinical outcomes were then compared between the groups. The Mini-Mental State Evaluation (abbreviated as MMSE1, MMSE2, MMSE3, and MMSE4) scale was used for the assessment of cognitive function, which was conducted on postoperative Days 2 (T1), 7 (T2), 14 (T3), and 28 (T4), with the score from postoperative Day 2 (MMSE1) considered as the primary observation.

RESULTS

Patients in Group L had higher MMSE1 scores compared to those in Group H (26.0 [24.0, 27.0] vs. 24.5 [22.0, 26.0], p = 0.046), and there was no significant difference in the scores between the groups at all subsequent time points. Group H exhibited a higher incidence of hypotension and bradycardia compared to Group L (p = 0.044 and p = 0.047, respectively).

CONCLUSIONS

Compared to a high dose (0.5-0.9 µg/kg/h) of DEX infusion, a low-dose (0.1-0.5 µg/kg/h) infusion started after induction of anesthesia and continued until 1 h before extubation improved postoperative cognitive function scores on postoperative Day 2 in patients aged 60 years and older.

TRIAL REGISTRATION

URL: www.chictr.org.cn with registration number ChiCTR2100055093, registered on 31/12/2021.

Preoperative slow-wave sleep is associated with postoperative delirium after heart valve surgery: A prospective pilot study

Postoperative delirium (POD) is a very common neurological complication after valve surgery. Some studies have shown that preoperative sleep disorder is associated with POD, but the correlation between preoperative slow wave sleep (SWS) and POD remains unclear. Therefore, this study aims to identify the correlation between preoperative slow wave sleep and postoperative delirium in patients with heart valve disease. This was a prospective, observational study of elective valve surgery patients admitted to the Heart Medical Center between November 2021 and July 2022. Polysomnography (PSG) was used to monitor sleep architecture from 9:30 p.m. for 1 night before surgery to 6:30 a.m. on the day of surgery. Patients were assessed for postoperative delirium from postoperative day 1 to extubation or day 5 by using the Richmond Agitation/Sedation Scale (RASS) and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). A total of 60 elective valve surgery patients were enrolled in this study. Prolonged N1 (11.44%) and N2 (58.62%) sleep, decreased N3 sleep (8.75%) and REM sleep (18.24%) within normal limits were the overall sleep architecture. Compared with patients without POD, patients with POD had less slow wave sleep 1 night before surgery (5.77% vs 10.88%, p < 0.001). After adjusting for confounding factors, slow wave sleep (OR: 0.647, 95% CI 0.493-0.851, p = 0.002) was found to be a protective factor for postoperative delirium. The preoperative SWS is a predictive factor of the POD in patients undergoing valve surgery. But further studies with larger sample sizes are still needed to elucidate the relationship between preoperative slow wave sleep and postoperative delirium.

Stellate ganglion block alleviates postoperative sleep disturbance in patients undergoing radical surgery for gastrointestinal malignancies

STUDY OBJECTIVES

We explored the effects of stellate ganglion block on postoperative sleep disturbance in patients scheduled to undergo radical surgery for gastrointestinal malignancies.

METHODS

Forty such patients were randomly assigned to the control group (Group C) or the preoperative stellate ganglion block treatment group (Group S). Using actigraphy, sleep quality was evaluated on the first night before the operation and first, second, and third postoperative nights. The Pittsburgh Sleep Quality Index scale was used for sleep state assessment on 1 day preoperatively and the first, second, third, fifth, and seventh days postoperatively. Plasma interleukin (IL)-1, IL-6, and IL-10 and melatonin levels were checked at 1 day preoperatively and the first and third days postoperatively. Mean arterial pressure, heart rate, and pulse oxygen saturation (SpO2) were recorded before general anesthesia induction, immediately after tracheal intubation, at the beginning of the operation, 1 and 2 hours after the beginning of the operation, at the end of the operation, immediately after extubation, and 30 minutes after transfer to the postanesthesia care unit.

RESULTS

Compared with Group C, in Group S sleep efficiency, total sleep time, and sleep maintenance were increased and sleep period change index, number of awakenings, wake after sleep onset, and body movements were reduced on the first and second postoperative nights; Pittsburgh Sleep Quality Index scores and occurrence of postoperative sleep disturbance were lower on the first and second nights postoperatively; IL-6 was reduced on the first night postoperatively; IL-1 and IL-10 were reduced on the third night postoperatively; melatonin was increased on the first night postoperatively; and mean arterial pressure and heart rate were decreased before general anesthesia induction, immediately after tracheal intubation, and at the end of the operation (all P < .05). Conclusions: Stellate ganglion block alleviates postoperative sleep disturbance by reducing postoperative inflammatory response, increasing melatonin levels, and stabilizing perioperative hemodynamics in patients undergoing radical surgery for gastrointestinal malignancies.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: The Effect of Stellate Ganglion Block on Postoperative Sleep Disturbance and Cognitive Function in Elderly Surgical Patients; URL: https://clinicaltrials.gov/ct2/show/NCT04800653; Identifier: NCT04800653.

CITATION

Yan S, Wang Y, Yu L, et al. Stellate ganglion block alleviates postoperative sleep disturbance in patients undergoing radical surgery for gastrointestinal malignancies. J Clin Sleep Med. 2023;19(9):1633-1642.

Circadian Rest-Activity Rhythms, Delirium Risk, and Progression to Dementia

OBJECTIVE

Delirium is a complex neurocognitive syndrome suspected to be bidirectionally linked to dementia. Circadian rhythm disturbances likely contribute to dementia pathogenesis, but whether these disturbances are related to delirium risk and progression to all-cause dementia is unknown.

METHODS

We analyzed continuous actigraphy data from 53,417 middle-aged or older UK Biobank participants during a median 5 years of follow-up. Four measures were used to characterize the 24-hour daily rest-activity rhythms (RARs): normalized amplitude, acrophase representing the peak activity time, interdaily stability, and intradaily variability (IV) for fragmentation of the rhythm. Cox proportional hazards models examined whether RARs predicted incident delirium (n = 551) and progression to dementia (n = 61).

RESULTS

Suppressed 24-hour amplitude, lowest (Q1) versus highest (Q4) quartile (hazard ratio [HR]Q1 vs Q4 = 1.94, 95% confidence interval [CI] = 1.53-2.46, p < 0.001), and more fragmented (higher IV: HRQ4 vs Q1 = 1.49, 95% CI = 1.18-1.88, p < 0.001) rhythms predicted higher delirium risk, after adjusting for age, sex, education, cognitive performance, sleep duration/disturbances, and comorbidities. In those free from dementia, each hour of delayed acrophase was associated with delirium risk (HR = 1.13, 95% CI = 1.04-1.23, p = 0.003). Suppressed 24-hour amplitude was associated with increased risk of progression from delirium to new onset dementia (HR = 1.31, 95% CI = 1.03-1.67, p = 0.03 for each 1-standard deviation decrease).

INTERPRETATION

Twenty-four-hour daily RAR suppression, fragmentation, and potentially delayed acrophase were associated with delirium risk. Subsequent progression to dementia was more likely in delirium cases with suppressed rhythms. The presence of RAR disturbances before delirium and prior to progression to dementia suggests that these disturbances may predict higher risk and be involved in early disease pathogenesis. ANN NEUROL 2023;93:1145-1157.

The prevalence and risk factors of sleep disturbances in surgical patients: A systematic review and meta-analysis

Determining the prevalence and risk factors related to sleep disturbance in surgical patients would be beneficial for risk stratification and perioperative care planning. The objectives of this systematic review and meta-analysis are to determine the prevalence and risk factors of sleep disturbances and their associated postoperative complications in surgical patients. The inclusion criteria were: (1) patients ≥18 years old undergoing a surgical procedure, (2) in-patient population, and (3) report of sleep disturbances using a validated sleep assessment tool. The systematic search resulted in 21,951 articles. Twelve patient cohorts involving 1497 patients were included. The pooled prevalence of sleep disturbances at preoperative assessment was 60% (95% Confidence Interval (CI): 50%, 69%) and the risk factors for postoperative sleep disturbances were a high preoperative Pittsburgh sleep quality index (PSQI) score indicating preexisting disturbed sleep and anxiety. Notably, patients with postoperative delirium had a higher prevalence of pre- and postoperative sleep disturbances and high preoperative wake after sleep onset percentage (WASO%). The high prevalence of preoperative sleep disturbances in surgical patients has a negative impact on postoperative outcomes and well-being. Further work in this area is warranted.

Association of Poor Sleep Burden in Middle Age and Older Adults With Risk for Delirium During Hospitalization

BACKGROUND

Delirium is a distressing neurocognitive disorder recently linked to sleep disturbances. However, the longitudinal relationship between sleep and delirium remains unclear. This study assessed the associations of poor sleep burden, and its trajectory, with delirium risk during hospitalization.

METHODS

About 321 818 participants from the UK Biobank (mean age 58 ± 8 years [SD]; range 37-74 years) reported (2006-2010) sleep traits (sleep duration, excessive daytime sleepiness, insomnia-type complaints, napping, and chronotype-a closely related circadian measure for sleep timing), aggregated into a sleep burden score (0-9). New-onset delirium (n = 4 775) was obtained from hospitalization records during a 12-year median follow-up. About 42 291 (mean age 64 ± 8 years; range 44-83 years) had repeat sleep assessment on average 8 years after their first.

RESULTS

In the baseline cohort, Cox proportional hazards models showed that moderate (aggregate scores = 4-5) and severe (scores = 6-9) poor sleep burden groups were 18% (hazard ratio = 1.18 [95% confidence interval: 1.08-1.28], p < .001) and 57% (1.57 [1.38-1.80], p < .001), more likely to develop delirium, respectively. The latter risk magnitude is equivalent to 2 additional cardiovascular risks. These findings appeared robust when restricted to postoperative delirium and after exclusion of underlying dementia. Higher sleep burden was also associated with delirium in the follow-up cohort. Worsening sleep burden (score increase ≥2 vs no change) further increased the risk for delirium (1.79 [1.23-2.62], p = .002) independent of their baseline sleep score and time lag. The risk was highest in those younger than 65 years at baseline (p for interaction <.001).

CONCLUSION

Poor sleep burden and worsening trajectory were associated with increased risk for delirium; promotion of sleep health may be important for those at higher risk.