Background Although spine surgery is frequent in older adults, the incidence, risk factors, and consequences of delirium in this population have not been well characterized. This is important since spine surgery is increasingly common, pain is a prominent symptom, and postoperative delirium may be preventable. Methods We enrolled 89 adults >70 y/o undergoing spine surgery in a prospective observational study. Postoperative delirium and delirium severity were assessed using validated methods, including the Confusion Assessment Method (CAM), CAM-ICU, Delirium Rating Scale-Revised-98, and chart review. Hospital-based outcomes were obtained from the medical record, and hospital charges from data reported to the state. Results Thirty-six patients (40.5%) developed delirium after spine surgery, with 17 (47.2%) having purely hypoactive features. Independent predictors of delirium were lower baseline cognition, higher average baseline pain, more IV fluid administered, and baseline anti-depressant medication. In adjusted models, the development of delirium was independently associated with increased quintile of length of stay (OR 3.66; 95%CI 1.48–9.04; p=0.005), increased quintile of hospital charges (OR 3.49; 95%CI 1.35–9.00; p=0.01), and decreased odds of discharge to home (OR 0.22; 95%CI 0.07–0.69; p=0.009). The severity of delirium was associated with increased quintile of hospital charges and decreased odds of discharge to home. Conclusion Delirium is common after spine surgery in older adults, and baseline pain is an independent risk factor. Delirium is associated with increased length of stay, increased charges, and decreased odds of discharge to home. Thus, prevention of delirium after spine surgery may represent an important quality improvement goal.

Background Delirium is a common complication after cardiac surgery and is associated with increased morbidity and mortality. However, whether rigorously-assessed postoperative delirium is associated with increased length of stay in the intensive care unit (LOS-ICU), length of stay (LOS), and hospital charges is not clear. Methods Patients (n=66) undergoing coronary artery bypass and/or valve surgery were enrolled in a nested cohort study. Rigorous delirium assessments were conducted using the Confusion Assessment Method. LOS-ICU and LOS were obtained from the medical record and hospital charges from administrative data reported to the state. Because of the skewed distribution of outcome variables, outcomes were compared using rank-sum tests, as well as median regression incorporating propensity scores. Results Patients who developed delirium (56%) vs. no delirium (43%) had increased median LOS-ICU (75.6 hours [IQR 43.6–136.8] vs. 29.7 hours [IQR 21.7–46.0]; p=0.002), increased median LOS (9 days [IQR 6–16] vs. 7 days [IQR 5–8]; p=0.006), and increased median hospital charges ($51,805 [IQR $44,041-$80,238] vs. $41,576 [IQR $35,748-$43,660]; P=0.002). In propensity score models adjusted for patient and surgical characteristics and complications, the results for LOS-ICU and cost remained highly significant, although the results for LOS were attenuated based on the specific statistical model. Increased severity of delirium was associated with both increased LOS-ICU and charges in a dose-response manner. Conclusions Delirium after cardiac surgery is independently associated with both increased length of stay-ICU and higher hospital charges. Since delirium is potentially preventable, targeted delirium-prevention protocols for high-risk patients may represent an important strategy for quality improvement.

; and the Cerebral Autoregulation Study Group IMPORTANCE Delirium occurs in up to 52% of patients after cardiac surgery and may result from changes in cerebral perfusion. Using intraoperative cerebral autoregulation monitoring to individualize and optimize cerebral perfusion may be a useful strategy to reduce the incidence of delirium after cardiac surgery. OBJECTIVE To determine whether targeting mean arterial pressure during cardiopulmonary bypass (CPB) using cerebral autoregulation monitoring reduces the incidence of delirium compared with usual care. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial nested within a larger trial enrolled patients older than 55 years who underwent nonemergency cardiac surgery at a single US academic medical center between October 11, 2012, and May 10, 2016, and had a high risk for neurologic complications. Patients, physicians, and outcome assessors were masked to the assigned intervention. A total of 2764 patients were screened, and 199 were eligible for analysis in this study. INTERVENTION In the intervention group, the patient's lower limit of cerebral autoregulation was identified during surgery before CPB. On CPB, the patient's mean arterial pressure was targeted to be greater than that patient's lower limit of autoregulation. In the control group, mean arterial pressure targets were determined according to institutional practice. MAIN OUTCOMES AND MEASURES The main outcome was any incidence of delirium on postoperative days 1 through 4, as adjudicated by a consensus expert panel. RESULTS Among the 199 participants in this study, mean (SD) age was 70.3 (7.5) years and 150 (75.4%) were male. One hundred sixty-two (81.4%) were white, 26 (13.1%) were black, and 11 (5.5%) were of other race. Of 103 patients randomized to usual care, 94 were analyzed, and of 102 patients randomized to the intervention 105 were analyzed. Excluding 5 patients with coma, delirium occurred in 48 of the 91 patients (53%) in the usual care group compared with 39 of the 103 patients (38%) in the intervention group (P = .04). The odds of delirium were reduced by 45% in patients randomized to the autoregulation group (odds ratio, 0.55; 95% CI, 0.31-0.97; P = .04). CONCLUSIONS AND RELEVANCE The results of this study suggest that optimizing mean arterial pressure to be greater than the individual patient's lower limit of cerebral autoregulation during CPB may reduce the incidence of delirium after cardiac surgery, but further study is needed. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00981474