Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery

Saljuqi, Abdul Tawab; Hanna, Kamil; Asmar, Samer; Tang, Andrew; Zeeshan, Muhammad; Gries, Lynn; Ditillo, Michael; Kulvatunyou, Narong; Castañón, Lourdes; Joseph, Bellal

doi:10.1016/j.jamcollsurg.2020.01.029

Cited by 38 publications

(33 citation statements)

References 24 publications

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“…The decision for general anesthesia may merely be a marker of advanced morbidity and thereby selecting a patient population particularly predisposed to POD due to common risk factors. In general, the identified risk factors are most likely independent from the TAVR procedure and have been reported in other contexts, e.g., orthopedic and general surgery (22,24).…”

Section: Discussionmentioning

confidence: 67%

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Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Mauri

Reuter

Körber

et al. 2021

Front. Cardiovasc. Med.

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Background: The aim of the present study was to analyze incidence, risk factors, and association with long-term outcome of postoperative delirium (POD) after transcatheter aortic valve replacement (TAVR).Methods: Six hundred and sixty one consecutive patients undergoing TAVR were prospectively enrolled from January 2016 to December 2017. POD was assessed regularly during ICU-stay using the CAM-ICU test.Results: The incidence of POD was 10.0% (n = 66). Patients developing POD were predominantly male (65%), had higher EuroSCORE II (5.4% vs. 3.9%; P = 0.041) and were more often considered frail (70% vs. 26%; P < 0.001). POD was associated with more peri-procedural complications including vascular complications (19.7 vs. 9.4; P = 0.017), bleeding (12.1 vs. 5.4%; P = 0.0495); stroke (4.5 vs. 0.7%; P = 0.025), respiratory failure requiring ventilation (16.7% vs. 1.8%; P < 0.001), and pneumonia (34.8% vs. 7.1%; P < 0.001). Consequently, patients with POD had significantly longer ICU- (7.9 vs. 3.2 days P < 0.001) and hospital-stay (14.9 vs. 9.0 days; P < 0.001), and higher in-hospital mortality (6.1 vs. 2.1%; P = 0.017). Logistic regression analysis identified male sex (odds ratio (OR) 2.2 [95% confidence interval (CI) 1.2–4.0); P = 0.012], atrial fibrillation [OR 3.0 (CI 1.6–5.6); P < 0.001], frailty [OR 4.3 (CI 2.4–7.9); P < 0.001], pneumonia [OR 4.4 (CI 2.3–8.7); P < 0.001], stroke [OR 7.0 (CI 1.2–41.6); P = 0.031], vascular complication [OR 2.9 (CI 1.3–6.3); P = 0.007], and general anesthesia [OR 2.0 (CI 1.0–3.7); P = 0.039] as independent predictors of POD. On Cox proportional hazard analysis POD emerged as a significant predictor of 2-year mortality [HR 1.89 (CI 1.06–3.36); P = 0.030].Conclusion: POD is a frequent finding after TAVR and is significantly associated with reduced 2-year survival. Predictors of delirium include not only peri-procedural parameters like stroke, pneumonia, vascular complications and general anesthesia but also baseline characteristics as male sex, atrial fibrillation and frailty.

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Section: Discussionmentioning

confidence: 67%

“…Also, frailty has been described as a predisposing factor of POD in general and as an important determinant of outcome after TAVR (12,24,26). Thereby, the predictive value was superior when frailty was assessed with objective tools instead of an informal "eyeball test" (4,27).…”

Section: Discussionmentioning

confidence: 99%

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Mauri

Reuter

Körber

et al. 2021

Front. Cardiovasc. Med.

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“…Old age, frailty, polypharmacy, comorbidities, and dementia are well-known risk factors for delirium in hospital patients, particularly postoperative delirium [26][27][28][29]. All these factors are common in hip fracture patients [7,8,19,[30][31][32][33][34], and even more so in those with dementia, resulting in delirium being a familiar complication on orthopedic wards.…”

Section: Discussionmentioning

confidence: 99%

“…All these factors are common in hip fracture patients [7,8,19,[30][31][32][33][34], and even more so in those with dementia, resulting in delirium being a familiar complication on orthopedic wards. Postoperative delirium episodes have been strongly linked to an increased mortality risk, especially in the emergency setting [28]. As it stands, multiple guidelines have been proposed recently to reduce the risk of delirium in geriatric patients, which may warrant further examination and further adjustment for patients with dementia [35][36][37].…”

Section: Discussionmentioning

confidence: 99%

The mortality burden in patients with hip fractures and dementia

Ioannidis

Ismail

Forssten

et al. 2021

Eur J Trauma Emerg Surg

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Purpose Dementia is strongly associated with postoperative death in patients subjected to hip fracture surgery. Nevertheless, there is a distinct lack of research investigating the cause of postoperative mortality in patients with dementia. This study aims to investigate the distribution and the risk of cause-specific postoperative mortality in patients with dementia compared to the general hip fracture population. Methods All adults who underwent emergency hip fracture surgery in Sweden between 1/1/2008 and 31/12/2017 were considered for inclusion. Pathological, conservatively managed fractures, and reoperations were excluded. The database was retrieved by cross-referencing the Swedish National Quality Registry for Hip Fracture patients with the Swedish National Board of Health and Welfare quality registers. A Poisson regression model was used to determine the association between dementia and all-cause as well as cause-specific 30-day postoperative mortality. Results 134,915 cases met the inclusion criteria, of which 20% had dementia at the time of surgery. The adjusted risk of all-cause 30-day postoperative mortality was 67% higher in patients with dementia after hip fracture surgery compared to patients without dementia [adj. IRR (95% CI): 1.67 (1.60–1.75), p < 0.001]. The risk of cause-specific mortality was also higher in patients with dementia, with up to a sevenfold increase in the risk cerebrovascular mortality [adj. IRR (95% CI): 7.43 (4.99–11.07), p < 0.001]. Conclusions Hip fracture patients with dementia have a higher risk of death in the first 30 days postoperatively, with a substantially higher risk of mortality due to cardiovascular, respiratory, and cerebrovascular events, compared to patients without dementia.

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“…Delirium is associated with serious adverse health outcomes, more pronounced in the emergency surgery setting. Geriatric patients with a hospital stay complicated by delirium are more likely to experience ICU admission, unplanned intubation, and a prolonged hospital stay, with increased mortality rates [ 51 ]. This underlines a major stress reaction that can be potentially mitigated or avoided if timely and effectively recognized.…”

Section: Beyond Age: Assessment Of Other Risk Factors That Impact The...mentioning

confidence: 99%

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

Mohseni

Joseph

Peden

2021

Eur J Trauma Emerg Surg

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As population age, healthcare systems and providers are likely to experience a substantial increase in the proportion of elderly patients requiring emergency surgery. Emergency surgery, compared with planned surgery, is strongly associated with increased risks of adverse postoperative outcomes due to the short time available for diagnosis, optimization, and intervention in patients presenting with physiological derangement. These patient populations, who are often frail and burdened with a variety of co-morbidities, have lower reserves to deal with the stress of the acute condition and the required emergency surgical intervention. In this review article, we discuss topical areas where mitigation of the physiological stress posed by the acute condition and asociated surgical intervention may be feasible. We consider the impact of the adrenergic response and use of beta blockers for these high-risk patients and discuss common risk factors such as frailty and delirium. A proactive multidisciplinary approach to peri-operative care aimed at mitigation of the stress response and proactive management of common conditions in the older emergency surgical patient could yield more favorable outcomes.

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Prospective Evaluation of Delirium in Geriatric Patients Undergoing Emergency General Surgery

Cited by 38 publications

References 24 publications

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

Incidence, Risk Factors and Impact on Long-Term Outcome of Postoperative Delirium After Transcatheter Aortic Valve Replacement

The mortality burden in patients with hip fractures and dementia

Mitigating the stress response to improve outcomes for older patients undergoing emergency surgery with the addition of beta-adrenergic blockade

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