The Age-adjusted Charlson Comorbidity Index predicts post-operative delirium in the elderly following thoracic and abdominal surgery: A prospective observational cohort study

Abstract

BackgroundPost-operative delirium (POD) presents as a serious neuropsychiatric syndrome in the elderly undergoing thoracic and abdominal surgery, which is mostly associated with poor prognosis. The Age-adjusted Charlson Comorbidity Index (ACCI) has been widely recognized as an independently predictive factor for overall survival rate and mortality in various surgeries. However, no studies demonstrated the potential relationship between ACCI and POD. The current study was to explore the correlation between ACCI and POD, and determine the predictive effect of ACCI on POD in the elderly after thoracic and abdominal surgery.Materials and methodsTotal 184 patients (≥60 years) who underwent thoracic and abdominal surgery from 2021.10 to 2022.5 were enrolled in this prospective observational cohort study. ACCI was calculated by weighting comorbidities and age. POD was diagnosed using Confusion Assessment Method (CAM) twice a day in the first 3 days after surgery. The Visual Analog Scale (VAS) was applied to measure pre-operative and post-operative pain at rest and in motion. All demographic and perioperative data were compared in patients with POD and without POD. ACCI and other variables were analyzed by univariate and multivariate logistic regression analysis. The characteristic curve of receiver operating characteristic (ROC) was used to further evaluate the accuracy of ACCI to predict POD.ResultsPost-operative delirium was diagnosed in 36 of 184 patients included in our study. The prevalence of POD in the elderly after thoracic and abdominal surgery was 19.6%. The outcomes by multivariate regression analysis showed the independent risk factors for POD were ACCI (OR: 1.834; 95%CI: 1.434–2.344; P < 0.001), pre-operative Mini-Mental State Examination (MMSE) scores (OR: 0.873; 95%CI: 0.767–0.994; P = 0.040), serum albumin (OR: 0.909; 95%CI: 0.826–1.000; P = 0.049) and pain scores in the post-operative third day (OR: 2.013; 95%CI: 1.459–2.778; P < 0.001). ACCI can predict POD more accurately with the largest area under curve (AUC) of 0.794 and sensitivity of 0.861, respectively.ConclusionAge-adjusted Charlson Comorbidity Index, pre-operative MMSE scores, serum albumin and post-operative pain were independently associated with POD in geriatric patients following thoracic and abdominal surgery. Moreover, ACCI may become an accurate indicator to predict POD early.

Predicting Postoperative Delirium in Older Patients: a multicenter retrospective cohort study

“…However, the absence of preoperative neuropsychological tests reduced the performance of POD prediction in the context of models solely relying on preoperative features (Figure 2-C), which is critical given that surgical and postoperative management could be optimized. Preoperative models with neuropsychological tests effectively predicted POD before surgery substantiating previous observations 13,28,51 . This could be attributed to preoperative neuropsychological tests revealing subtle cognitive deficits, despite less than 2% of dementia diagnoses before surgery in this study cohort (eTable 1).…”

“…Patients with mild cognitive impairment at baseline are more likely to develop POD 25 , while good preoperative cognitive performance is protective against POD 18 . Previous studies have often used the MMSE 28,31,55 , Clock-Drawing Test 20 , or MOCA score as preoperative risk factors 56 . Critically, we replicated the strong association between baseline MOCA and POD risk in the previous theory-driven PAWEL-R study with a larger cohort 13 .…”

“…The Type and length of surgery and anesthesia are indispensable for POD prediction 18,27 . Although preoperative neuropsychological assessments, like the Mini-Mental State Examination (MMSE) and others [28][29][30] , help identify at-risk patients for early risk mitigation [31][32][33] , these evaluations…”

“…The Type and length of surgery and anesthesia are indispensable for POD prediction 18,27 . Although preoperative neuropsychological assessments, like the Mini-Mental State Examination (MMSE) and others 28–30 , help identify at-risk patients for early risk mitigation 31–33 , these evaluations are not yet incorporated in clinical routine despite experts’ recommendations 34 . The early identification of POD risk factors enables clinicians to proactively mitigate the occurrence of POD 35 and might affect patient’s decision before non-emergent surgery.…”

Effects of sarcopenia and frailty on postoperative recovery in elderly patients: A prospective cohort study

“…Demographic characteristics and clinical data were collected from each participant. The co‐morbidities graded using the age‐adjusted Charlson co‐morbidity index (aCCI), 17 the Morse Fall Scale score, 18 nutritional status (assessed using the Malnutrition Universal Screening Tool), 19 activities of daily living (evaluated using Barthel index), 20 sleep quality (measured using numeric rating scale; 0–10, 0 = very dissatisfied, 10 = very satisfied) were evaluated by trained, employed nurses of our department. The operative stress score (OSS) was used to categorize procedures as low (1–2), moderate (3) and high (4–5) stress 21 .…”