Neighborhood‐Level Social Disadvantage and Risk of Delirium Following Major Surgery

Abstract

BACKGROUND/OBJECTIVES Delirium is a common postoperative complication associated with prolonged length of stay, hospital readmission, and premature mortality. We explored the association between neighborhood‐level characteristics and delirium incidence and severity, and compared neighborhood‐ with individual‐level indicators of socioeconomic status in predicting delirium incidence. DESIGN A prospective observational cohort of patients enrolled between June 18, 2010, and August 8, 2013. Baseline interviews were conducted before surgery, and delirium/delirium severity was evaluated daily during hospitalization. Research staff evaluating delirium were blinded to baseline cognitive status. SETTING Two academic medical centers in Boston, MA. PARTICIPANTS A total of 560 older adults, aged 70 years or older, undergoing major noncardiac surgery. INTERVENTION The Area Deprivation Index (ADI) was used to characterize each neighborhood's socioeconomic disadvantage. MEASUREMENTS Delirium was assessed using the Confusion Assessment Method (CAM) long form. Delirium severity was calculated using the highest value of CAM Severity score (CAM‐S) occurring during daily hospital assessments (CAM‐S Peak). RESULTS Residing in the most disadvantaged neighborhoods (ADI > 44) was associated with a higher risk of incident delirium (12/26; 46%), compared with the least disadvantaged neighborhoods (122/534; 23%) (risk ratio (RR) (95% confidence interval (CI)) = 2.0 (1.3–3.1). The CAM‐S Peak score was significantly associated with ADI (Spearman rank correlation, ρ = 0.11; P = .009). Mean CAM‐S Peak scores generally rose from 3.7 to 5.3 across levels of increasing neighborhood disadvantage. The RR (95% CI) values associated with individual‐level markers of socioeconomic status and cultural background were: 1.2 (0.9–1.7) for education of 12 years or less; 1.3 (0.8–2.1) for non‐White race; and 1.7 (1.1–2.6) for annual household income of less than $20,000. None of these individual‐level markers exceeded the ADI in terms of effect size or significance for prediction of delirium risk. CONCLUSIONS Neighborhood‐level makers of social disadvantage are associated with delirium incidence and severity, and demonstrated an exposure‐response relationship. Future studies should consider contextual‐level metrics, such as the ADI, as risk markers of social disadvantage that can help to guide delirium treatment and prevention.

Neighborhood Disadvantage and Active, Disabled and Total Life Expectancy Among Community-living Older Persons

“…31 Addressing these and other disparities in resource-poor environments will require substantial investments to support a more robust set of social and public health interventions. 30,32 Based on the accumulating evidence linking socioeconomically disadvantaged neighborhoods to an increasing number of adverse health outcomes, [1][2][3][4] these investments could potentially lead to cost savings through large-scale reduction of inequalities in morbidity and mortality. 32,33 The outcomes evaluated in the current study, active and disabled life expectancy, are important not only to policy-makers, but also to older persons who consistently identify the maintenance of independent function as their top health outcome priority.…”

“…A neighborhood may be disadvantaged based on indicators of education, employment, housing-quality and poverty. Prior research has shown that living in a socioeconomically disadvantaged neighborhood confers increased risk for several adverse outcomes including all-cause mortality, 1 hospital readmission, 2 the incidence and severity of delirium after major surgery, 3 and Alzheimer disease neuropathology. 4 Active and disabled life expectancy, defined as the projected number of remaining years without and with disability in activities of daily living, are often used by policy-makers to forecast the functional well-being of older persons.…”

“…A neighborhood may be disadvantaged based on indicators of education, employment, housing-quality and poverty. Prior research has shown that living in a socioeconomically disadvantaged neighborhood confers increased risk for several adverse outcomes including all-cause mortality, 1 hospital readmission, 2 the incidence and severity of delirium after major surgery, 3 and Alzheimer disease neuropathology. 4…”

High-Mobility Group Box-1 and Its Potential Role in Perioperative Neurocognitive Disorders

“…There are several mutations on the HMGB1 gene that have been noted to increase the levels of circulating HMGB1 [83], however, the relevance of these mutations for the development of PND has not been established. Plasma HMGB1 levels were noted to be higher in an African American cohort compared to a Caucasian one [77], while the relative risk of developing postoperative delirium may be greater (1.3) for non-whites; the 95% confidence intervals crossed unity (0.8-2.1) [84]; the entire effect may reflect social disadvantage.…”

A framework of social determinants of health for delirium tailored to older adults

“…First, we have previously demonstrated that the Area Deprivation Index, a social determinant of health indicating neighborhood poverty and disadvantage, was an important risk factor for incident delirium and delirium severity. 11 Second, accumulating evidence from electrophysiologic, 12 neuroimaging, 13,14 and biomarker studies of delirium 15 has indicated that underlying brain vulnerability, even in the absence of cognitive impairment or dementia, is an important risk factor for delirium. Third, cognitive reserve and resilience play important roles in delirium risk.…”