Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults

Abstract

Importance Major postoperative complications and delirium contribute independently to adverse outcomes and high resource utilization in patients undergoing major surgery; however, their inter-relationship is not well-examined. Objective To evaluate the association of major postoperative complications and delirium, alone and in combination, with adverse outcomes after surgery. Design Prospective cohort study. Setting Two large academic medical centers. Participants Patients without recognized dementia or history of delirium, age 70 and older who underwent elective major orthopedic, vascular, and abdominal surgeries with a minimum 3-day hospitalization. Main Outcome and Measures Major postoperative complications, defined as life altering or threatening events (Accordion Severity ≥ grade 2), were identified by expert panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated chart review method. Four subgroups were analyzed: (1) no complications, no delirium; (2) complications alone; (3) delirium alone; and (4) both complications and delirium. Adverse outcomes included length of stay (LOS) > 5 days, institutional discharge, and rehospitalization within 30 days of discharge. Results Of 566 participants, mean age (±SD) was 76.7± 5.2 years, 42% male and 92% white. Forty-seven (8%) developed major complications, and 135 (24%) developed delirium. When compared to no complications, no delirium as the reference group, major complications alone contributed only to prolonged LOS (RR 2.8, 95% CI 1.9–4.0); by contrast, delirium alone significantly increased all adverse outcomes, including prolonged LOS (RR 1.9, 95% CI 1.4–2.7), institutional discharge (RR 1.5, 95% CI 1.3–1.7), and 30-day readmission (RR 2.3, 95% CI 1.4–3.7). The subgroup with both complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR 3.4, 95% CI 2.3–4.8), institutional discharge (RR 1.8, 95% CI 1.4–2.5) and 30-day readmission (RR 3.0, 95% CI 1.3–6.8). Delirium exerted the highest attributable risk at a population level (5.8%, 95% CI 4.7–6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). Conclusions and Relevance Major postoperative complications and delirium are separately associated with adverse events and demonstrate a strong combined effect. Delirium occurs more frequently, and has greater impact at the population level than other major complications.

185 The Prevalence of Undiagnosed Pre-Surgical Cognitive Impairment and Its Post-Surgical Clinical Impact in Elderly Patients Undergoing Surgery for Adult Spinal Deformity

“…In a study of 144 elderly patients undergoing a major surgery, Robinson et al found that postoperative delirium was significantly associated with increased length of hospital stay, post-discharge institutionalization, and 6-month mortality rates (17). Similarly, in a prospective study of 566 elderly patients who underwent an elective major surgery, Gleason et al demonstrated that post-operative delirium without major post-operative complications was significantly associated with not only increased length of hospital stay, but also 30-day readmissions (18). Our study found that pre-operative CI was associated with increased rates of post-operative delirium and increased likelihood of discharge to a post-acute care facility.…”

Risk factors of cervical surgery related complications in patients older than 80 years

“…These potential systemic after-effects, which cannot be detected by the general preoperative examinations, such as blood test, radiography, electrocardiography or echocardiography, may be related to our result that cancer history is a risk factor for major complications, even with no cancer recurrence. Regarding history of cerebrovascular disorders as a risk factor for overall complications, it is well reported that cerebrovascular disease is significantly associated with the incidence of delirium 22,23) . These may relate to our results because postoperative delirium was the most popular complication in our cohort.…”

“…Koji Tamai 1) , Hidetomi Terai 1) , Akinobu Suzuki 1) , Hiroaki Nakamura 1) , Masaomi Yamashita 2) , Yawara Eguchi 3) , Shiro Imagama 4) , Kei Ando 4) , Kazuyoshi Kobayashi 4) , Morio Matsumoto 5) , Ken Ishii 5) , Tomohiro Hikata 5) , Shoji Seki 6) , Masaaki Aramomi 7) , Tetsuhiro Ishikawa 7) , Atsushi Kimura 8) , Hirokazu Inoue 8) , Gen Inoue 9) , Masayuki Miyagi 9) , Wataru Saito 9) , Kei Yamada 10) , Michio Hongo 11) , Kenji Endo 12) , Hidekazu Suzuki 12) , Atsushi Nakano 13) , Kazuyuki Watanabe 14) , Junichi Ohya 15) , Hirotaka Chikuda 15) , Yasuchika Aoki 16) , Masayuki Shimizu 17) , Toshimasa Futatsugi 17) , Keijiro Mukaiyama 17) , Masaichi Hasegawa 18) , Katsuhito Kiyasu 19) , Haku Iizuka 20) , Kotaro Nishida 21) , Kenichiro Kakutani 21) , Hideaki Nakajima 22) , Hideki Murakami 23) , Satoru Demura 23) , Satoshi Kato 23) , Katsuhito Yoshioka 23) , Takashi Namikawa 24) , Kei Watanabe 25) …”

Association of postoperative delirium with markers of neurodegeneration and brain amyloidosis: a pilot study

“…Although delirium is defined by its acute onset, it is now clear that it is associated with subsequent loss of independence, increased risk of mortality, and long-term cognitive decline and dementia, even in the absence of presurgery cognitive impairment (Bellelli et al, 2014;Gleason et al, 2015). The multifactor theory for postoperative delirium (POD) etiology in elderly postulates that vulnerable brain could be less resilient to various stressors, leading to acute brain dysfunctions and to further inability to return to the previous levels of functioning (Inouye et al, 2014).…”