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Journal of General Internal Medicine
Published in: Journal of General Internal Medicine 4/2018

Open Access 01-04-2018 | Review Paper

Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis

Authors: Jennifer Watt, MD, FRCPC, Andrea C. Tricco, MSc, PhD, Catherine Talbot-Hamon, MD, FRCPC, Ba’ Pham, MSc, PhD, Patricia Rios, MSc, Agnes Grudniewicz, PhD, Camilla Wong, MHSc, MD, FRCPC, Douglas Sinclair, MD, CCFP(EM), FRCPC, Sharon E. Straus, MSc, MD, FRCPC

Published in: Journal of General Internal Medicine | Issue 4/2018

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Abstract

Background

Postoperative delirium is a common preventable complication experienced by older adults undergoing elective surgery. In this systematic review and meta-analysis, we identified prognostic factors associated with the risk of postoperative delirium among older adults undergoing elective surgery.

Methods

Medline, EMBASE, CINAHL, Cochrane Central Register of Controlled Trials, and AgeLine were searched for articles published between inception and April 21, 2016. A total of 5692 titles and abstracts were screened in duplicate for possible inclusion. Studies using any method for diagnosing delirium were eligible. Two reviewers independently completed all data extraction and quality assessments using the Cochrane Risk-of-Bias Tool for randomized controlled trials (RCTs) and the Newcastle-Ottawa Scale (NOS) for cohort studies. Random effects meta-analysis models were used to derive pooled effect estimates.

Results

Forty-one studies (9384 patients) reported delirium-related prognostic factors. Among our included studies, the pooled incidence of postoperative delirium was 18.4% (95% confidence interval [CI] 14.3–23.3%, number needed to follow [NNF] = 6). Geriatric syndromes were important predictors of delirium, namely history of delirium (odds ratio [OR] 6.4, 95% CI 2.2–17.9), frailty (OR 4.1, 95% CI 1.4–11.7), cognitive impairment (OR 2.7, 95% CI 1.9–3.8), impairment in activities of daily living (ADLs; OR 2.1, 95% CI 1.6–2.6), and impairment in instrumental activities of daily living (IADLs; OR 1.9, 95% CI 1.3–2.8). Potentially modifiable prognostic factors such as psychotropic medication use (OR 2.3, 95% CI 1.4–3.6) and smoking status (OR 1.8 95% CI 1.3–2.4) were also identified. Caregiver support was associated with lower odds of postoperative delirium (OR 0.69, 95% CI 0.52–0.91).

Discussion

Though caution must be used in interpreting meta-analyses of non-randomized studies due to the potential influence of unmeasured confounding, we identified potentially modifiable prognostic factors including frailty and psychotropic medication use that should be targeted to optimize care.
Appendix
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Literature
1.
Bakker RC, Osse RJ, Tulen JHM, Kappetein AP, Bogers AJJC. Preoperative and operative predictors of delirium after cardiac surgery in elderly patients. Eur J Cardiothorac Surg 2012;41:544–549.CrossRefPubMed
2.
Veliz-Reissmuller G, Agüero Torres H, van der Linden J; Lindblom D, Eriksdotter Jonhagen M. Pre-operative mild cognitive dysfunction predicts risk for post-operative delirium after elective cardiac surgery. Aging Clin Exp Res 2007;19:172–177.CrossRefPubMed
3.
Patti R, Saitta M, Cusumano G, Termine G, Di Vita G. Risk factors for postoperative delirium after colorectal surgery for carcinoma. Eur J Oncol Nurs 2011;15:519–523.CrossRefPubMed
4.
Witlox J, Eurelings LS, de Jonghe JF, Kalisvaart KJ, Eikelenboom P, van Gool WA. Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis. JAMA 2010;304(4):443–451.CrossRefPubMed
5.
Inouye SK, Bogardus ST, Jr, Charpentier PA, et al. A multicomponent intervention to prevent delirium in hospitalized older patients. N Engl J Med 1999;340(9):669–676.
6.
Chen C, Li H, Liang J, et al. Effect of a modified hospital elder life program on delirium and length of stay in patients undergoing abdominal surgery: a cluster randomized clinical trial. JAMA Surg. 2017;152(9):827–834.
7.
8.
Mohanty S, Rosenthal RA, Russell MM, et al. Optimal perioperative management of the geriatric patient: best practices guideline from the American College of Surgeons NSQIP and the American Geriatrics Society. J Am Coll Surg. 2016;222(5):930–947.
9.
Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol 2009;62(10):e1–34.CrossRefPubMed
10.
Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. meta-analysis of observational studies in epidemiology (MOOSE) group. JAMA. 2000;283(15):2008–2012.CrossRefPubMed
11.
Juurlink D, Preyra C, Croxford R, et al. Canadian Institute for Health Information Discharge Abstract Database: A Validation Study. Toronto: Institute for Clinical Evaluative Sciences;2006.
12.
Tousignant M, Corriveau H, Roy PM, Desrosiers J, Dubuc N, Hebert R. Efficacy of supervised Tai Chi exercises versus conventional physical therapy exercises in fall prevention for frail older adults: a randomized controlled trial. Disabil Rehabil. 2013;35(17):1429–1435.CrossRefPubMed
13.
Gianoudis J, Bailey CA, Ebeling PR, et al. Effects of a targeted multimodal exercise program incorporating high-speed power training on falls and fracture risk factors in older adults: a community-based randomized controlled trial. J Bone Miner Res. 2014;29(1):182–191.CrossRefPubMed
14.
Wells G, Shea B, O’Connell D, et al. The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-Analyses. Ottawa, Ontario: Ottawa Hospital Research Institute;2008.
15.
16.
Cochrane Effective Practice and Organization Care Group. EPOC risk of bias tool. 2011.
17.
Sanchez-Meca J, Marin-Martinez F, Chacon-Moscoso S. Effect-size indices for dichotomized outcomes in meta-analysis. Psychol Methods 2003;8(4):448–467.CrossRefPubMed
18.
Higgins J, Green SE. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration. 2011. Available from www.​handbook.​cochrane.​org.
19.
20.
Duval S, Tweedie R. Trim and fill: A simple funnel-plot-based method of testing and adjusting for publication bias in meta-analysis. Biometrics. 2000;56(2):455–463.CrossRefPubMed
21.
Viechtbauer W. Conducting meta-analyses in R with the metafor package. 2010;36(3):48.
22.
Schwarzer G. meta: an R package for meta-analysis. R News. 2007;7(3):40–45.
23.
Olin K, Eriksdotter-Jonhagen M, Jansson A, Herrington MK, Kristiansson M, Permert J. Postoperative delirium in elderly patients after major abdominal surgery. Br J Surg. 2005;92(12):1559–1564.CrossRefPubMed
24.
Priner M, Jourdain M, Bouche G, Merlet-Chicoine I, Chaumier JA, Paccalin M. Usefulness of the short IQCODE for predicting postoperative delirium in elderly patients undergoing hip and knee replacement surgery. Gerontology. 2008;54(2):116–119.CrossRefPubMed
25.
Freter SH, Dunbar MJ, MacLeod H, Morrison M, MacKnight C, Rockwood K. Predicting post-operative delirium in elective orthopaedic patients: the Delirium Elderly At-Risk (DEAR) instrument. Age Ageing. 2005;34(2):169–171.CrossRefPubMed
26.
Large MC, Reichard C, Williams JT, et al. Incidence, risk factors, and complications of postoperative delirium in elderly patients undergoing radical cystectomy. Urology. 2013;81(1):123–128.CrossRefPubMed
27.
Flink BJ, Rivelli SK, Cox EA, et al. Obstructive sleep apnea and incidence of postoperative delirium after elective knee replacement in the nondemented elderly. Anesthesiology. 2012;116:788–796.CrossRefPubMedPubMedCentral
28.
Rogers MP, Liang MH, Daltroy LH, Eaton H, Peteet J, Wright E, Albert M. Delirium after elective orthopedic surgery: risk factors and natural history. Int J Psychiatry Med. 1989;19:109–121.CrossRefPubMed
29.
Jankowski CJ, Trenerry MR, Cook DJ, et al. Cognitive and functional predictors and sequelae of postoperative delirium in elderly patients undergoing elective joint arthroplasty. Anesth Analg. 2011;112(5):1186–1193.CrossRefPubMed
30.
Kudoh A, Takase H, Takahira Y, Takazawa T. Postoperative confusion increases in elderly long-term benzodiazepine users. Anesth Analg. 2004;99:1674–1678.CrossRefPubMed
31.
Eriksson M, Samuelsson E, Gustafson Y, Aberg T, Engstrom KG. Delirium after coronary bypass surgery evaluated by the organic brain syndrome protocol. Scand Cardiovasc J. 2002;36(4):250–255.CrossRefPubMed
32.
Fukuse T, Satoda N, Hijiya K, Fujinaga T. Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest. 2005;127:886–891.CrossRefPubMed
33.
Otomo S, Maekawa K, Goto T, Baba T, Yoshitake A. Pre-existing cerebral infarcts as a risk factor for delirium after coronary artery bypass graft surgery. Interact Cardiovasc Thorac Surg. 2013;17(5):799–804.CrossRefPubMedPubMedCentral
34.
Rolfson DB, McElhaney JE, Rockwood K, et al. Incidence and risk factors for delirium and other adverse outcomes in older adults after coronary artery bypass graft surgery. Can J Cardiol. 1999;15(7):771–776.PubMed
35.
Kristjansson SR, Nesbakken A, Jordhøy MS, et al. Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study. Crit Rev Oncol Hematol. 2010;76:208–217.CrossRefPubMed
36.
Santos FS, Velasco IT, Fraguas R, Jr Risk factors for delirium in the elderly after coronary artery bypass graft surgery. Int Psychogeriatr. 2004;16(2):175–193.
37.
Koebrugge B, Koek HL, van Wensen RJ, Dautzenberg PL, Bosscha K. Delirium after abdominal surgery at a surgical ward with a high standard of delirium care: incidence, risk factors and outcomes. Dig Surg. 2009;26(1):63–68.CrossRefPubMed
38.
Morimoto Y, Yoshimura M, Utada K, Setoyama K, Matsumoto M, Sakabe T. Prediction of postoperative delirium after abdominal surgery in the elderly. J Anesth. 2009;23(1):51–56.CrossRefPubMed
39.
Papaioannou A, Fraidakis O, Michaloudis D, Balalis C, Askitopoulou H. The impact of the type of anaesthesia on cognitive status and delirium during the first postoperative days in elderly patients. Eur J Anesthesiol. 2005;22:492–499.CrossRef
40.
Kosar CM, Tabloski PA, Travison TG, et al. Effect of preoperative pain and depressive symptoms on the risk of postoperative delirium: a prospective cohort study. Lancet Psychiatry. 2014;1:431–436.CrossRefPubMedPubMedCentral
41.
Leung JM, Sands LP, Lim E, Tsai TL, Kinjo S. Does preoperative risk for delirium moderate the effects of postoperative pain and opiate use on postoperative delirium? Am J Geriatr Psychiatry. 2013;21(10):946–956.CrossRefPubMedPubMedCentral
42.
Tognoni P, Simonato A, Robutti N, et al. Preoperative risk factors for postoperative delirium (POD) after urological surgery in the elderly. Arch Gerontol Geriatr. 2011;52:e166–e169.CrossRefPubMed
43.
Hattori H, Kamiya J, Shimada H, et al. Assessment of the risk of postoperative delirium in elderly patients using E-PASS and the NEECHAM Confusion Scale. Int J Geriatr Psychiatry. 2009;24(11):1304–1310.CrossRefPubMed
44.
Visser L, Prent A, Van Der Laan MJ, et al. Predicting postoperative delirium after vascular surgical procedures. J Vasc Surg. 2015;62:185–189.CrossRef
45.
Clement ND, MacDonald D, Howie CR, Biant LC. The outcome of primary total hip and knee arthroplasty in patients aged 80 years or more. J Bone Joint Surg Br. 2011;93(9):1265–1270.CrossRefPubMed
46.
Rudolph JL, Jones RN, Rasmussen LS, Silverstein JH, Inouye SK, Marcantonio ER. Independent vascular and cognitive risk factors for postoperative delirium. Am J Med. 2007;120(9):807–813.CrossRefPubMed
47.
Robinson TN, Wu DS, Pointer LF, Dunn CL, Moss M. Preoperative cognitive dysfunction is related to adverse postoperative outcomes in the elderly. J Am Coll Surg. 2012;215(1):12–17.CrossRefPubMedPubMedCentral
48.
Mohanty S, Rosenthal RA, Russell MM, Neuman MD, Ko CY, Esnaola NF. Optimal perioperative management of the geriatric patient: best practices guideline from ACS NSQIP/American Geriatrics Society. J Am Coll Surg. 2016;222(5):930–947.CrossRefPubMed
49.
Gani H, Domi R, Kodra N, et al. The incidence of postoperative delirium in elderly patients after urologic surgery. Med Arch. 2013;67(1):45–47.CrossRefPubMed
50.
Cerejeira J, Batista P, Nogueira V, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. Low preoperative plasma cholinesterase activity as a risk marker of postoperative delirium in elderly patients. Age Ageing. 2011;40:621–626.CrossRefPubMed
51.
Brouquet A, Cudennec T, Benoist S, et al. Impaired mobility, ASA status and administration of tramadol are risk factors for postoperative delirium in patients aged 75 years or more after major abdominal surgery. Ann Surg. 2010;251(4):759–765.CrossRefPubMed
52.
Fisher BW, Flowerdew G. A simple model for predicting postoperative delirium in older patients undergoing elective orthopedic surgery. J Am Geriatr Soc. 1995;43(2):175–178.CrossRefPubMed
53.
Scholz AFM, Oldroyd C, McCarthy K, Quinn TJ, Hewitt J. Systematic review and meta-analysis of risk factors for postoperative delirium among older patients undergoing gastrointestinal surgery. Br J Surg. 2016;103:e21–e28.CrossRefPubMed
54.
Rhodes L, Miles G, Pearson A. Patient subjective experience and satisfaction during the perioperative period in the day surgery setting: a systematic review. Int J Nurs Pract. 2006;12:178–192.CrossRefPubMed
55.
Yang Y, Zhao X, Dong T, Yang Z, Zhang Q, Zhang Y. Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis. Aging Clin Exp Res. 2016:1–12.
56.
Xue P, Wu Z, Wang K, Tu C, Wang X. Incidence and risk factors of postoperative delirium in elderly patients undergoing transurethral resection of prostate: a prospective cohort study. Neuropsychiatr Dis Treat. 2016;12:137–142.CrossRefPubMedPubMedCentral
57.
Hempenius L, Slaets JPJ, van Asselt D, de Bock TH, Wiggers T, van Leeuwen BL. Long term outcomes of a geriatric liaison intervention in frail elderly cancer patients. PLoS One. 2016;11:e0143364.CrossRefPubMedPubMedCentral
58.
Raats JW, Steunenberg SL, Crolla RMPH, Wijsman JHH, te Slaa A, van der Laan L. Postoperative delirium in elderly after elective and acute colorectal surgery: a prospective cohort study. Int J Surg. 2015;18:216–219.CrossRefPubMed
59.
Sasajima Y, Sasajima T, Azuma N, et al. Factors related to postoperative delirium in patients with lower limb ischaemia: a prospective cohort study. Eur J Vasc Endovasc Surg. 2012;44(4):411–415.CrossRefPubMed
60.
Dasgupta M, Rolfson DB, Stolee P, Borrie MJ, Speechley M. Frailty is associated with postoperative complications in older adults with medical problems. Arch Gerontol Geriatr. 2009;48:78-83.CrossRefPubMed
61.
Blakoe M, Greve H. Frailty - preoperative assessment and implications for nursing practice following heart surgery. Paper presented at: EuroHeartCare 2015; Dubrovnik, Croatia.
62.
Min L, Mazzurco L, Gure TR, et al. Longitudinal functional recovery after geriatric cardiac surgery. J Surg Res. 2015;194:25–33.CrossRefPubMed
63.
Suh DH, Kim J-W, Kim HS, Chung HH, Park NH, Song YS. Pre- and intra-operative variables associated with surgical complications in elderly patients with gynecologic cancer: the clinical value of comprehensive geriatric assessment. J Geriatr Oncol. 2014;5:315–322.CrossRefPubMed
64.
Kim K-I, Park K-H, Koo K-H, Han H-S, Kim C-H. Comprehensive geriatric assessment can predict postoperative morbidity and mortality in elderly patients undergoing elective surgery. Arch Gerontol Geriatr. 2013;56:507–512.CrossRefPubMed
65.
Inouye SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz RI. Clarifying confusion: the confusion assessment method. a new method for detection of delirium. Ann Intern Med. 1990;113(12):941–948.CrossRefPubMed
66.
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington (VA): American Psychiatric Association; 2013.
67.
Thomsen T, Villebro N, Moller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014(3):Cd002294.
68.
Tannenbaum C, Martin P, Tamblyn R, Benedetti A, Ahmed S. Reduction of inappropriate benzodiazepine prescriptions among older adults through direct patient education: the EMPOWER cluster randomized trial. JAMA Intern Med. 2014;174(6):890–898.CrossRefPubMed
69.
70.
Muscedere J, Andrew MK, Bagshaw SM, et al. Screening for frailty in Canada’s health care system: a time for action. Can J Aging. 2016;35(3):281–297.CrossRefPubMed
71.
Ng T, Feng L, Nyunt M, et al. Nutritional, physical, cognitive, and combination interventions and frailty reversal among older adults: a randomized controlled trial. Am J Med. 2015;128(11):1225–1236.CrossRefPubMed
72.
Singh NA, Quine S, Clemson LM, et al. Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial. J Am Med Dir Assoc. 2012;13:24–30.CrossRefPubMed
73.
Theou O, Stathokostas L, Roland KP, et al. The effectiveness of exercise interventions for the management of frailty: a systematic review. J Aging Res. 2011;569194.
74.
Abdullah HR, Lien VP, Ong HK, et al. Protocol for a single-centre, randomised controlled study of a preoperative rehabilitation bundle in the frail and elderly undergoing abdominal surgery. BMJ Open. 2017;e016815.
75.
Martinez FT, Tobar C, Beddings CI, Vallejo G, Fuentes P. Preventing delirium in an acute hospital using a non-pharmacological intervention. Age Ageing. 2012;41(5):629–634.CrossRefPubMed
76.
Hsieh SJ, Shum M, Lee AN, Hasselmark F, Gong MN. Cigarette smoking as a risk factor for delirium in hospitalized and intensive care unit patients: a systematic review. Ann Am Thorac Soc. 2013;10(5):496–503.CrossRefPubMedPubMedCentral
77.
Metadata
Title
Identifying Older Adults at Risk of Delirium Following Elective Surgery: A Systematic Review and Meta-Analysis
Authors
Jennifer Watt, MD, FRCPC
Andrea C. Tricco, MSc, PhD
Catherine Talbot-Hamon, MD, FRCPC
Ba’ Pham, MSc, PhD
Patricia Rios, MSc
Agnes Grudniewicz, PhD
Camilla Wong, MHSc, MD, FRCPC
Douglas Sinclair, MD, CCFP(EM), FRCPC
Sharon E. Straus, MSc, MD, FRCPC
Publication date
01-04-2018
Publisher
Springer US
Published in
Journal of General Internal Medicine / Issue 4/2018
Print ISSN: 0884-8734
Electronic ISSN: 1525-1497
DOI
https://doi.org/10.1007/s11606-017-4204-x

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