Incidence and Risk Factors of Postoperative Delirium

Czech version

Authors: A. Mitášová ¹; L. Mitáš ²; I. Urbánek ¹; L. Ryba ³; I. Hanke ²; M. Ruber ⁴; R. Michalčáková ¹; M. Košťálováihash2 ^{1,5 1,5}
Authors‘ workplace: Neurologická klinika LF MU a FN Brno ¹; Chirurgická klinika LF MU a FN Brno ²; Ortopedická klinika LF MU a FN Brno ³; Klinika úrazové chirurgie LF MU a FN Brno ⁴; CEITEC – Středoevropský technologický institut MU, Brno ⁵
Published in: Cesk Slov Neurol N 2012; 75/108(5): 574-580
Category: Original Paper

Overview

Introduction:
Postoperative delirium (POD) is a frequent complication of a surgery with negative effect on postoperative treatment and rehabilitation, duration of hospitalization and long-term prognosis. The aim was to assess the incidence and evaluate importance of risk factors of POD in patients who underwent elective spine and pulmonary surgery and emergency hip fracture surgery, and to compare the incidence of POD with that of post-stroke delirium.

Patients and methods:
Development of POD was evaluated prospectively using the Czech version of the CAM-ICU – a screening test for detection of delirium and the DSM-IV criteria for delirium in a group of 94 patients (54 women; age: 69; 32–99 yrs – median; range) who had a surgery for symptomatic lumbar spine stenosis (23 patients – A1), pulmonary neoplasm (31 patients – A2) or a hip fracture (40 patients – B). The incidence of POD was compared with that of delirium in age- and sex-matched group of stroke patients (n = 94; 54 women; age: 70; 45–91 yrs – median; range). Significance of predisposing and precipitating perioperative risk factors for delirium was analysed.

Results:
The incidence of POD was 7.4%; 3.7% in elective surgery patients and 12.5% in emergency hip fracture surgery patients. The authors explain low incidence of POD by low prevalence of preoperative cognitive deficit in elective surgery subgroup (A1 + A2) – 7.4% compared to 17.5% in group B and 22.3% in stroke patients. The low incidence of perioperative complications (11.7%) was the other possible factor influencing low incidence of POD. However, no significant risk factor for POD was identified, possibly due to low incidence of POD. The incidence of post-stroke delirium was significantly higher compared to that of POD (33.0%; p <0.001).

Conclusions:
The incidence of POD in elective surgery patients remains low as a result of mini-invasive surgery, considerate anaesthesia and effective management and prevention of perioperative complications. On the contrary, the incidence of post-stroke delirium is significantly higher, thus confirming the role of primary brain involvement as an independent precipitating risk factor for delirium.

Key words:
postoperative delirium – risk factors – incidence

Sources

1. Bednařík J. Delirium: nová výzva pro neurologii? Cesk Slov Neurol N 2006; 69/102(1): 18–26.

2. Quinlan N, Rudolph JL. Postoperative delirium and functional decline after noncardiac surgery. J Am Geriatr Soc 2011; 59 (Suppl 2): S301–S304.

3. Gao R, Yang Z, Li M, Shi Z, Fu Q. Probable risk factors for postoperative delirium in patients undergoing spinal surgery. Eur Spine J 2008; 17(11): 1531–1537.

4. Sieber FE, Zakriya KJ, Gottschalk A, Glute MR, Lee HB, Rosenberg PB et al. Sedation depth during spinal anesthesia and the development of postoperative delirium in elderly patients undergoing hip fracture repair. Mayo Clin Proc 2010; 85(1): 18–26.

5. Shioiri A, Kurumaji A, Takeuchi T, Matsuda H, Arai H, Nishikawa T. White matter abnormalities as a risk factor for postoperative delirium revealed by diffusion tensor imaging. Am J Geriatr Psychiatry 2010; 18(8): 743–753.

6. Afonso A, Scurlock C, Reich D, Raikhelkar J, Hossain S, Bodian C et al. Predictive Model for Postoperative Delirium in Cardiac Surgical Patients. Semin Cardiothorac Vasc Anesth 2010; 14(3): 212.

7. Tei M, Ikeda M, Haraguchi N, Takemasa I, Mizushima T, Ishii H. Risk factors for postoperative delirium in elderly patients with colorectal cancer. Surg Endosc 2010; 24(9): 2135–2139.

8. Mangnall LT, Gallagher R, Stein-Parbury J. Postoperative delirium after colorectal surgery in older patients. Am J Crit Care 2010; 20(1): 45–55.

9. Yildizeli B, Ozyurtkan MO, Batirel HF, Kuscu K, Bekiroglu N, Yüksel M. Factors Associated With Postoperative Delirium After Thoracic Surgery. Ann Thorac Surg 2005; 79(3): 1004–1009.

10. Ozyurtkan MO, Yildizeli B, Kuşçu K, Bekiroğlu N, Bostanci K, Batirel HF et al. Postoperative psychiatric disorders in general thoracic surgery: incidence, risk factors and outcomes. Eur J Cardiothorac Surg 2010; 37(5): 1152–1157.

11. Koster S, Hensens G, Schuurmans MJ, Palen J. Risk factors of delirium after cardiac surgery. A systematic review. Eur J Cardiovasc Nurs 2011; 10(4): 197–204.

12. Ushida T, Yokoyama T, Kishida Y, Hosokawa M, Taniguchi S, Inoue S et al. Incidence and risk factors of postoperative delirium in cervical spine surgery. Spine 2009; 34(23): 2500–2504.

13. Tognoni P, Simonato A, Robutti N, Pisani M, Cataldi A, Monacelli F et al. Preoperative risk factors for postoperative delirium (POD) after urological surgery in the elderly. Arch Gerontol Geriatr 2010; 52(3): e166–e169.

14. Mitášová A, Bednařík J, Košťálová M, Michalčáková R, Ježková M, Kašpárek T et al. Standardizace české verze The Confusion Assessment Method for the Intensive Care Unit (CAM-ICUcz). Cesk Slov Neurol N 2010; 73/106(3): 258–266.

15. Mitasova A, Kostalova M, Bednarik J, Michalcakova R, Kasparek T, Balabanova P et al. Poststroke delirium incidence and outcomes: Validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2012; 40(2): 484–490.

16. Kostalova M, Mitasova A, Bednarik J, Dusek L, Michalcakova R, Kerkovsky M et al. Towards a predictive model for post-stroke delirium. Brain Injury 2012; 26(7–8): 962–971.

17. 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.

18. Ely EW, Inouye SK, Bernard GR, Gordon S, Francis J, May L et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286(21): 2703–2710.

19. Ely EW, Margolin R, Francis J, May L, Truman B, Dittus R et al. Evaluation of delirium in critically ill patients: validation of the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Crit Care Med 2001; 29(7): 1370–1379.

20. Sessler CN, Gosnell M, Grap MJ, Brophy GT, O‘Neal PV, Keane KA et al. The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care patients. Am J Respir Crit Care Med 2002; 166(10): 1338–1344.

21. Ely EW, Truman B, Shintani A, Thomason JWW, Wheeler AP, Gordon S et al. Monitoring sedation status over time in ICU patients: the reliability and validity of the Richmond Agitation Sedation Scale (RASS). JAMA 2003; 289(22): 2983–2991.

22. Stagno D, Gibson C, Breitbart W. The delirium subtypes: a review of prevalence, phenomenology, pathophysiology, and treatment response. Palliat Support Care 2004; 2(2): 171–179.

23. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association 2000.

24. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant R. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmfull alcohol consumption. II. Addiction 1993; 88(6): 791–804.

25. Hummelová-Fanfrdlová Z, Rektorová I, Sheardová K, Bartoš A, Línek V, Ressner P et al. Česká adaptace Addenbrookského kognitivního testu. Cesk psychol 2009; 53(4): 376– 388.

26. Zung WW, Richards CB, Short MJ. Self-rarting depression scale in an outpatient clinic. Further validation of the SDS. Arch Gen Psychiatry 1965; 13(6): 508–515.

27. Crum RM, Anthony JC, Bassett SS, Folstein MF. Population-based norms for the mini-mental state examination by age and educational level, JAMA 1993; 369(18): 2386–2391.

28. Blessed G, Tomlinson BE, Roth M. The association between quantitative measures of dementia and of senile change in the cerebral grey matter of elderly subjects. Br J Psychiatry 1968; 114(512): 797–811.

29. Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Brit J Anaest 2009; 103 (Suppl 1): i41–i46.

30. Ansaloni L, Catena F, Chattat R, Fortuna D, Franceschi C, Mascitti P et al. Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery. Brit J Surg 2010; 97(2): 273–280.

31. Bitsch M, Foss N, Kristensen B, Kehlet H. Pathogenesis of and management strategies for postoperative delirium after hip fracture. Acta Orthop Scand 2004; 75(4): 378–389.

32. Gallo J, Čechová I, Zapletalová J. Časné komplikace provázející TEP kyčle u fraktur krčku femuru. Acta Chir Orthop Traumatol Čech 2010; 77(5): 389–394.

33. Schuurmans MJ, Shortridge-Baggett LM, Duursma SA. The Delirium Observation Screening Scale: a screening instrument for delirium. Res Theory Nurs Pract 2003 Spring; 17(1): 31–50.

34. Trzepacz PT, Mittal D, Torres R, Kanary K, Norton J, Jimerson N. Validation of the Delirium Rating Scale-revised-98: comparison with the delirium rating scale and the cognitive test for delirium. J Neuropsychiatry Clin Neurosci 2001 Spring; 13(2): 229–242.

35. Bergeron N, Dubois MJ, Dumont M, Dial S, Skrobik Y. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27(5): 859–864.

36. Tully PJ, Baker RA, Winefield HR, Turnbull DA. Depression, anxiety disorders and Type D personality as risk factors for delirium after cardiac surgery. Aust N Z J Psychiatry 2010; 44(11): 1005–1111.

37. Plaschke K, Fichtenkamm P, Schramm P, Hauth S, Martin E, Verch M at al. Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6. Intensive Care Med 2010; 36(12): 2081–2089.

38. Klugkist M, Sedemund-Adib B, Schmidtke C, Schmucker P, Sievers HH, Hüppe M. Confusion Assessment Method for the Intensive Care Unit (CAM-ICU): diagnosis of postoperative delirium in cardiac surgery. Anaesthesist 2008; 57(5): 464–474.

39. Hudetz JA, Iqbal Z, Gandhi SD, Patterson KM, Byrne AJ, Pagel PS. Postoperative delirium and short-term cognitive dysfunction occur more frequently in patients undergoing valve surgery with or without coronary artery bypass graft surgery compared with coronary artery bypass graft surgery alone: results of a pilot study. J Cardiothorac Vasc Anesth 2011; 25(5): 811–816.

40. Burkhart CS, Dell-Kuster S, Gamberini M, Moeckli A, Grapow M, Filipovic M et al. Modifiable and nonmodifiable risk factors for postoperative delirium after cardiac surgery with cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2010; 24(4): 555–559.

41. Lee HJ, Hwang DS, Wang SK, Chee IS, Baeg S, Kim JL. Early assessment of delirium in elderly patients after hip surgery. Psychiatry Investig 2011; 8(4): 340–347.