Derivation of a simple postoperative delirium incidence and severity prediction model

SummaryBackgroundDelirium is an important postoperative complication, yet a simple and effective delirium prediction model remains elusive. We hypothesized that the combination of the National Surgical Quality Improvement Program (NSQIP) risk calculator for serious complications (NSQIP-SC) or risk of death (NSQIP-D), and cognitive tests of executive function (Trail Making Test A and B [TMTA, TMTB]), could provide a parsimonious model to predict postoperative delirium incidence or severity.MethodsData were collected from 100 adults (≥65yo) undergoing major non-cardiac surgery. In addition to NSQIP-SC, NSQIP-D, TMTA and TMTB, we collected participant age, sex, ASA score, tobacco use, type of surgery, depression, Framingham risk score, and preoperative blood pressure. Delirium was diagnosed with the Confusion Assessment Method (CAM), and the Delirium Rating Scale-R-98 (DRS) was used to assess symptom severity. LASSO and Best Subsets logistic and linear regression were employed in line with TRIPOD guidelines.ResultsThree participants were excluded due to intraoperative deaths (2) and alcohol withdrawal (1). Ninety-seven participants with a mean age of 71.68±4.55, 55% male (31/97 CAM+, 32%) and a mean Peak DRS of 21.5±6.40 were analyzed. Of the variables included, only NSQIP-SC and TMTB were identified to be predictors of postoperative delirium incidence (p<0.001, AUROC 0.81, 95% CI: 0.72, 0.90) and severity (p<0.001, Adj. R2: 0.30).ConclusionsIn this cohort, preoperative NSQIP-SC and TMTB were identified as predictors of postoperative delirium incidence and severity. Future studies should verify whether this two-factor model could be used for accurate delirium prediction.

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Validation of a Postoperative Delirium Prediction Model

Proceedings of IMPRS ◽

10.18060/23422 ◽

2019 ◽

Vol 2 (1) ◽

Author(s):

Ashok Biju, B.S. ◽

Babar Khan, M.D. M.S. ◽

Heidi . Lindroth, Ph.D. R.N

Keyword(s):

Thoracic Surgery ◽

Prediction Model ◽

Postoperative Delirium ◽

Rating Scale ◽

Predictor Variable ◽

Secondary Data ◽

Assessment Method ◽

Appreciable Effect ◽

Improvement Program ◽

Cognitive Measure

Background and Hypothesis: A prediction model utilizing the National Surgical Quality Improvement Program risk calculator for serious complications (NSQIPSC) and measures of cognitive function has been demonstrated to predict postoperative delirium incidence and severity in patients after non-cardiac surgery. The next step is to test this model’s generalizability by validating in different patient populations and evaluating the robustness of the model with and without parameters of cognition. We hypothesized that the prediction model would still function in predicting postoperative delirium in patients undergoing major thoracic surgery. Experimental Design or Project Methods: A secondary data analysis of a randomized clinical trial involving 135 individuals who underwent major thoracic surgery from October 2013 to June 2015 was done. Delirium incidence and severity were tracked postoperatively through the Confusion Assessment Method for the ICU (CAM-ICU) and the Delirium Rating Scale-R-98 (DRS), respectively. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) was used to assess preoperative cognition. Linear regressions and specificity/sensitivity calculations were performed to evaluate the model. Results: One hundred and thirty-two patients with a mean age of 59±13 years, 33/132 CAM-ICU+, and a mean DRS peak of 3.12±3.43 were analyzed. Linear regression of NSQIP-SC scores moderately predicted delirium severity (P<0.001, Adjusted R2: 0.28). Addition of a cognitive measure did not significantly improve the model (P<0.001, Adjusted R2: 0.29). NSQIP-SC moderately predicted delirium incidence (sensitivity: 60.61%, specificity: 68.69%, AUROC: 0.73). Addition of a cognitive measure (sensitivity: 61.54%, specificity: 68.69%, AUROC: 0.73) did not significantly improve the model. Conclusion and Potential Impact: NSQIP-SC was a predictor variable for delirium incidence and severity. Addition of a cognitive measure did not have any appreciable effect on the prediction model. Further expanding the scope of the model can grant clinicians a tool to identify patients at risk for developing postoperative delirium.

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Risk Factors and Incidence of Postoperative Delirium in Patients Undergoing Laryngectomy

Otolaryngology ◽

10.1177/0194599819864304 ◽

2019 ◽

Vol 161 (5) ◽

pp. 807-813 ◽

Cited By ~ 2

Author(s):

Yiru Wang ◽

Huiqian Yu ◽

Hui Qiao ◽

Chan Li ◽

Kaizheng Chen ◽

...

Keyword(s):

Risk Factors ◽

Postoperative Delirium ◽

Rating Scale ◽

Multivariable Analysis ◽

Diagnostic Algorithm ◽

Target Population ◽

Confusion Assessment Method ◽

Assessment Method ◽

Factors Associated ◽

The Mean

Objective To explore the risk factors and incidence of postoperative delirium (POD) in patients undergoing laryngectomy for laryngeal cancer. Study Design Prospective cohort study. Setting Shanghai Eye, Ear, Nose, and Throat Hospital, Fudan University. Subjects and Methods A total of 323 patients underwent laryngectomy from April 4, 2018, to December 28, 2018. Perioperative data were collected. The primary outcome was the presence of POD as defined by the Confusion Assessment Method diagnostic algorithm. Univariate and multivariable logistic regression analyses were used to identify risk factors associated with POD. Results Of the patients who underwent laryngectomy during the study period, 99.1% were male, with a mean age of 60.0 years. Of these patients, 28 developed POD, with most episodes (88.1%) occurring during the first 3 postoperative days. The type of POD was hyperactive in 7 cases and hypoactive in 21 cases. The mean duration of POD was 1 day. The mean Delirium Rating Scale-Revised-98 score (a measure of POD severity) was 11.5. For the multivariable analysis, risk factors associated with POD included advanced cancer stage, lower educational level, higher American Society of Anesthesiologists classification, and intraoperative hypotension lasting at least 30 minutes. Intraoperative dexmedetomidine use was protective against POD. Conclusion This study identified risk factors associated with POD, providing a target population for quality improvement initiatives. Furthermore, intraoperative dexmedetomidine use can reduce POD.

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Preoperative Cerebrospinal Fluid Cortisol and the Risk of Postoperative Delirium: A Prospective Study of Older Hip Fracture Patients

Dementia and Geriatric Cognitive Disorders ◽

10.1159/000512984 ◽

2020 ◽

Vol 49 (6) ◽

pp. 604-610

Author(s):

Joost Witlox ◽

Dimitrios Adamis ◽

Leo Koenderman ◽

Kees Kalisvaart ◽

Jos F.M. de Jonghe ◽

...

Keyword(s):

Risk Factors ◽

Cerebrospinal Fluid ◽

Hip Fracture ◽

Postoperative Delirium ◽

Rating Scale ◽

The Elderly ◽

Confusion Assessment Method ◽

Assessment Method ◽

Cortisol Levels ◽

A Prospective Study

Background: Ageing, depression, and neurodegenerative disease are common risk factors for delirium in the elderly. These risk factors are associated with dysregulation of the hypothalamic-pituitary-adrenal axis, resulting in higher levels of cortisol under normal and stressed conditions and a slower return to baseline. Objectives: We investigated whether elevated preoperative cerebrospinal fluid (CSF) cortisol levels are associated with the onset of postoperative delirium. Methods: In a prospective cohort study CSF samples were collected after cannulation for the introduction of spinal anesthesia of 75 patients aged 75 years and older admitted for surgical repair of acute hip fracture. Delirium was assessed with the confusion assessment method (CAM) and the Delirium Rating Scale-Revised-98 (DRS-R98). Because the CAM and DRS-R98 were available for time of admission and 5 postoperative days, we used generalized estimating equations and linear mixed modeling to examine the association between preoperative CSF cortisol levels and the onset of postoperative delirium. Results: Mean age was 83.5 (SD 5.06) years, and prefracture cognitive decline was present in one-third of the patients (24 [33%]). Postoperative delirium developed in 27 (36%) patients. We found no association between preoperative CSF cortisol levels and onset or severity of postoperative delirium. Conclusions: These findings do not support the hypothesis that higher preoperative CSF cortisol levels are associated with the onset of postoperative delirium in elderly hip fracture patients.

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Postoperative delirium after cardiac surgery of elderly patients as an independent risk factor for prolonged length of stay in intensive care unit and in hospital

Aging Clinical and Experimental Research ◽

10.1007/s40520-021-01842-x ◽

2021 ◽

Author(s):

Andrea Kirfel ◽

Jan Menzenbach ◽

Vera Guttenthaler ◽

Johanna Feggeler ◽

Andreas Mayr ◽

...

Keyword(s):

Intensive Care Unit ◽

Cardiac Surgery ◽

Intensive Care ◽

Length Of Stay ◽

Elderly Patients ◽

Postoperative Delirium ◽

Confusion Assessment Method ◽

Assessment Method ◽

Hospital Length Of Stay ◽

Confusion Assessment

Abstract Background Postoperative delirium (POD) is a relevant and underdiagnosed complication after cardiac surgery that is associated with increased intensive care unit (ICU) and hospital length of stay (LOS). The aim of this subgroup study was to compare the frequency of tested POD versus the coded International Statistical Classification of Diseases and Related Health Problems (ICD) diagnosis of POD and to evaluate the influence of POD on LOS in ICU and hospital. Methods 254 elective cardiac surgery patients (mean age, 70.5 ± 6.4 years) at the University Hospital Bonn between September 2018 and October 2019 were evaluated. The endpoint tested POD was considered positive, if one of the tests Confusion Assessment Method for ICU (CAM-ICU) or Confusion Assessment Method (CAM), 4 'A's Test (4AT) or Delirium Observation Scale (DOS) was positive on one day. Results POD occurred in 127 patients (50.0%). LOS in ICU and hospital were significantly different based on presence (ICU 165.0 ± 362.7 h; Hospital 26.5 ± 26.1 days) or absence (ICU 64.5 ± 79.4 h; Hospital 14.6 ± 6.7 days) of POD (p < 0.001). The multiple linear regression showed POD as an independent predictor for a prolonged LOS in ICU (48%; 95%CI 31–67%) and in hospital (64%; 95%CI 27–110%) (p < 0.001). The frequency of POD in the study participants that was coded with the ICD F05.0 and F05.8 by hospital staff was considerably lower than tests revealed by the study personnel. Conclusion Approximately 50% of elderly patients who underwent cardiac surgery developed POD, which is associated with an increased ICU and hospital LOS. Furthermore, POD is highly underdiagnosed in clinical routine.

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Evaluation of point-of-care thumb-size bispectral electroencephalography device to quantify delirium severity and predict mortality

The British Journal of Psychiatry ◽

10.1192/bjp.2021.101 ◽

2021 ◽

pp. 1-8

Author(s):

Takehiko Yamanashi ◽

Kaitlyn J. Crutchley ◽

Nadia E. Wahba ◽

Eleanor J. Sullivan ◽

Katie R. Comp ◽

...

Keyword(s):

Rating Scale ◽

Point Of Care ◽

Confusion Assessment Method ◽

Assessment Method ◽

Negative Group ◽

Positive Group ◽

Prediction Of Mortality ◽

Eeg Data ◽

Poor Outcomes ◽

Screening Scale

Background We have developed the bispectral electroencephalography (BSEEG) method for detection of delirium and prediction of poor outcomes. Aims To improve the BSEEG method by introducing a new EEG device. Method In a prospective cohort study, EEG data were obtained and BSEEG scores were calculated. BSEEG scores were filtered on the basis of standard deviation (s.d.) values to exclude signals with high noise. Both non-filtered and s.d.-filtered BSEEG scores were analysed. BSEEG scores were compared with the results of three delirium screening scales: the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU), the Delirium Rating Scale-Revised-98 (DRS) and the Delirium Observation Screening Scale (DOSS). Additionally, the 365-day mortalities and the length of stay (LOS) in the hospital were analysed. Results We enrolled 279 elderly participants and obtained 620 BSEEG recordings; 142 participants were categorised as BSEEG-positive, reflecting slower EEG activity. BSEEG scores were higher in the CAM-ICU-positive group than in the CAM-ICU-negative group. There were significant correlations between BSEEG scores and scores on the DRS and the DOSS. The mortality rate of the BSEEG-positive group was significantly higher than that of the BSEEG-negative group. The LOS of the BSEEG-positive group was longer compared with that of the BSEEG-negative group. BSEEG scores after s.d. filtering showed stronger correlations with delirium screening scores and more significant prediction of mortality. Conclusions We confirmed the usefulness of the BSEEG method for detection of delirium and of delirium severity, and prediction of patient outcomes with a new EEG device.

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CSF PGRN May be Associated With Postoperative Delirium After Knee Replacement in Elderly Patients: The PNDABLE Study

10.21203/rs.3.rs-138907/v1 ◽

2021 ◽

Author(s):

Bin Wang ◽

Jie Xiu Sun ◽

He Tao ◽

Yuan Xi Deng ◽

Nan Ya Lin ◽

...

Keyword(s):

Postoperative Delirium ◽

Cognitive Disorders ◽

Diagnostic Value ◽

Confusion Assessment Method ◽

Assessment Method ◽

Chinese Patients ◽

Roc Curve Analysis ◽

Duration Of Surgery ◽

Total Knee ◽

T Tau

Abstract BackgroundPostoperative delirium (POD) represents a serious complication following anesthesia and surgical procedures for patients undergoing surgical intervention (1). Little is known about the mechanisms underlying similarities in the core features between postoperative delirium (POD) and progranulin (PGRN)-related cognitive disorders. We herein investigated the relationship between preoperative CSF PGRN concentration and POD occurrence in the Han Chinese patients undergoing unilateral total knee arthroplasty.MethodsWe conducted an observational, prospective, and 1:1 matched (on age older than 65, the unilateral total knee arthroplasty, American Society of Anesthesiologist’ (ASA) physical status, duration of surgery, and intraoperative bleeding) case-control study. POD cases and non-POD controls were selected from the overall cohort using Confusion Assessment Method (CAM). Delirium severity was measured by the Memorial Delirium Assessment Scale (MDAS). CSF PGRN and core biomarkers were measured by ELISA using the microplate reader. The associations of CSF PGRN levels with POD risk and CSF core biomarkers were assessed.ResultsPOD incidence was 9.7% (53/545). There were significant differences in preoperative CSF PGRN concentration between POD patients and controls (P<0.001), and CSF PGRN levels increased with age, as demonstrated by a significantly positive correlation (r=0.796, P<0.001).CSF PGRN levels to increase with CAM scores and MDAS scores, as demonstrated by significantly positive correlations (r=0.693, P<0.001; r=0.590, P<0.001). There were positive associations of CSF PGRN with T-tau (β = -0.501, P < 0.001) and P-tau (β = -0.470, P < 0.001) and negative associations of CSF PGRN with Aβ1–42 (β = -0.576, P < 0.001), Aβ1–40 (β = -0.488, P < 0.001), Aβ42/p-tau (β = -0.422, P < 0.001), and Aβ42 / T- tau (β = -0.395, P < 0.001) in POD patients. The ROC curve analysis of PGRN showed that PGRN concentrations had high diagnostic value for POD.ConclusionsCSF PGRN may be associated with the POD. Aβ pathology is associated with a decrease in CSF PGRN in the absence of tau deposition and neurodegeneration, whereas tau pathology and neurodegeneration is associated with an increase in CSF PGRN.Clinical Trial Registrationwww.clinicaltrials.gov, identifier ChiCTR2000033439.

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Postoperative Delirium after Urological Surgery: A Literature Review

Current Urology ◽

10.1159/000499280 ◽

2019 ◽

Vol 13 (3) ◽

pp. 133-140 ◽

Cited By ~ 2

Author(s):

Ioannis Leotsakos ◽

Ioannis Katafigiotis ◽

Ofer N. Gofrit ◽

Mordechai Duvdevani ◽

Dionysios Mitropoulos

Keyword(s):

Risk Factors ◽

Literature Search ◽

Postoperative Delirium ◽

Mini Mental State Examination ◽

Confusion Assessment Method ◽

Assessment Method ◽

Factors Associated ◽

Confusion Assessment ◽

Urological Surgery ◽

State Examination

Purpose: We aimed to thoroughly search and identify studies referring to risk factors associated with postoperative delirium (POD) in patients undergoing open as well as en-doscopic urological surgery. Methods: The review after a systematic literature search included 5 studies. Results: The incidence of POD was reported to be between 7.8 and 30% depending on the type of the urologic surgery, while in the majority of the studies the onset happened on the first postoperative day and the symptoms lasted 3 ± 0.8 days. Seventeen different risk factors for POD were identified and presented in detail. Conclusion: The Mini-Mental State Examination score and older age were significantly associated with the development of POD. However, the Confusion Assessment Method is very well validated against the diagnosis of delirium from the specialists.

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Serum protein S100 as marker of postoperative delirium after off-pump coronary artery bypass surgery: secondary analysis of two prospective randomized controlled trials

Clinical Chemistry and Laboratory Medicine (CCLM) ◽

10.1515/cclm-2015-1012 ◽

2016 ◽

Vol 54 (10) ◽

Cited By ~ 12

Author(s):

Layth Al Tmimi ◽

Marc Van de Velde ◽

Bart Meyns ◽

Bart Meuris ◽

Paul Sergeant ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Postoperative Delirium ◽

Artery Bypass ◽

Confusion Assessment Method ◽

Assessment Method ◽

Off Pump ◽

Confusion Assessment ◽

Opcab Surgery ◽

Pump Coronary Artery Bypass

AbstractBackground:To investigate the predictive value of S100 (biochemical marker of neuroglial injury) for the occurrence of postoperative delirium (POD) in patients undergoing off-pump coronary artery bypass (OPCAB)-surgery.Methods:We enrolled 92 patients older than 18 years undergoing elective OPCAB-surgery. Serum-levels of S100 were determined at baseline (BL), end of surgery (EOS) and on the first postoperative day (PD1). Postoperatively, all-patients were evaluated daily until PD5 for the presence of POD using the confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) for patients in the intensive care unit (ICU).Results:The overall incidence of POD was 21%. S100-values on PD1 significantly predicted the occurrence of POD during the later hospital stay [area under the curve (AUC)=0.724 (95% confidence interval (CI): 0.619–0.814); p=0.0001] with an optimal cut-off level of 123 pg mLConclusions:S100-levels <123 pg mL

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Delirium classification by the diagnostic and statistical manual – a moving target

International Psychogeriatrics ◽

10.1017/s1041610215000502 ◽

2015 ◽

Vol 27 (6) ◽

pp. 881-882 ◽

Cited By ~ 4

Author(s):

Karin J. Neufeld

Keyword(s):

Rating Scale ◽

Confusion Assessment Method ◽

Assessment Method ◽

Classification Systems ◽

Diagnostic Systems ◽

Delirium Assessment ◽

Diagnostic And Statistical Manual ◽

Dsm 5 ◽

Medical Inpatients ◽

Dsm Iv

The following paper, entitled “A Comparison of Delirium Diagnosis in Elderly Medical Inpatients using the CAM, DRS-R98, DSM-IV and DSM-5 Criteria” by Adamis and colleagues, reports the results of a single delirium assessment of 200 medical inpatients, aged 70 years and older. The aim was to compare the prevalence of delirium using two different diagnostic classification systems (DSM-5 and DSM-IV) and two commonly used research tools (Confusion Assessment Method and the Delirium Rating Scale-Revised ‘98). This editorial focuses on the comparison of the two versions of the DSM. The authors conclude that, while both diagnostic systems identify a core concept of delirium, the DSM-IV criteria are the most inclusive of the four approaches and the DSM-5, the most restrictive, identifying a prevalence of 19.5% and 13%, respectively in this sample. Furthermore, they conclude that these two systems do not appear to detect the same patients: only 14 of 26 (54%) individuals identified as delirious by the more exclusive DSM-5 criteria were also identified as such by DSM-IV.

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Implementation of Strategies to Prevent and Treat Postoperative Delirium in the Post Anesthesia Caring Unit. A German Survey of Current Practice

10.21203/rs.2.13335/v1 ◽

2019 ◽

Author(s):

Thomas Saller ◽

Klaus F. Hofmann-Kiefer ◽

Isabel Saller ◽

Simon T. Schaefer ◽

Bernhard Zwissler ◽

...

Keyword(s):

Intensive Care ◽

Postoperative Delirium ◽

Standard Procedure ◽

Confusion Assessment Method ◽

Assessment Method ◽

Psychotic Symptoms ◽

Ambulatory Anesthesia ◽

Web Based ◽

Nursing Delirium Screening Scale ◽

Current Guidelines

Abstract Background Postoperative delirium is associated with worse outcome. The aim of this study is to understand present strategies for delirium screening and therapy in German Post Anesthesia Caring Units (PACU) in hospitals and ambulatory anesthesia facilities. Methods We designed German-wide web-based survey of 922 leading anesthesiologists in hospitals and 726 in ambulatory surgery. Results The response rate was 30% for hospital anesthesiologists. 10% (95%-confidence interval: 8–12) of the anesthesiologists applied a standardised screening for delirium. Even though not on a regular basis, in 44% (41–47) of the hospitals, a recommended and validated screening was used, the Nursing Delirium Screening Scale (NuDesc) or the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). If delirium is likely to occur, 46% (43–50) of the patients were examined using a delirium tool and 20% (17–23) screened in intensive care units. For the treatment of delirium, alpha-2-agonists (83%, 80–85) were used most frequently for vegetative symptoms, benzodiazepines in anxiety in 71% (68–74), typical neuroleptics in 77% (71–82%) of patients with psychotic symptoms and in 20% (15–25) of patients with hypoactive delirium. 45% (39–51) of the respondents suggested no therapy for this entity. One third of the respondents indicated an age limit for pre-anesthetic medication with a mean age (SD) of 74.2 (±6.4) years and avoid benzodiazepines. Conclusions Monitoring of delirium was not established as a standard procedure in German PACUs. However, symptom-oriented therapy for postoperative delirium corresponded with the current guidelines.

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