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Background: Postoperative delirium (POD) is a severe perioperative complication that may increase mortality and length-of-stay in older patients. Moreover, POD is a major economic burden to any healthcare system. An altered expression of Acetylcholine- and Butyrylcholinesterases (AChE, BuChE) due to an unbalanced neuroinflammatory response to trauma or an operative stimulus has been reported to play an essential role in the development of POD. We investigated if perioperative measurement of cholinesterases (ChEs) can help identifying patients at risk for the occurrence of POD in both, scheduled and emergency surgery patients., Methods: This monocentric prospective observational cohort study was performed in a tertiary hospital (departments of orthopaedic surgery and traumatology). One hundred and fifty-one patients aged above 75 years were enrolled for scheduled (n = 76) or trauma-related surgery (n = 75). Exclusion criteria were diagnosed dementia and anticholinergic medication. Plasma samples taken pre- and postoperatively were analysed regarding AChE and BuChE activity. Furthermore, perioperative assessment using different cognitive tests was performed. The type of anaesthesia (general vs. spinal anaesthesia) was analysed. Primary outcome was the incidence of POD assessed by the approved Confusion Assessment Method (CAM) in combination with the expression of AChE and BuChE., Results: Of 151 patients included, 38 (25.2%) suffered from POD; 11 (14%) in scheduled and 27 (36%) in emergency patients. AChE levels showed no difference throughout groups or time course. Trauma patients had lower BuChE levels prior to surgery than scheduled patients (p < 0.001). Decline in BuChE levels correlated positively with the incidence of POD (1669 vs. 1175 U/l; p < 0.001). Emergency patients with BuChE levels below 1556 U/L were at highest risk for POD. There were no differences regarding length of stay between groups or incidence of POD. The type of anaesthesia had no influence regarding the incidence of POD. Only Charlson Comorbidity Index and Mini Nutrition Assessment demonstrated reliable strength in respect of POD., Conclusions: Perioperative measurement of BuChE activity can be used as a tool to identify patients at risk of POD. As a point-of-care test, quick results may alter the patients' course prior to the development of POD., Trial Registration: https://drks.de/search/de/trial/DRKS00017178 ., (© 2024. The Author(s).)

A delirium in patients in the intensive care unit (ICU) is a manifestation of a severe acute dysfunction of the brain. It has a high prevalence and is associated with a relevant increase in morbidity and mortality. A cholinergic deficit and dopaminergic overactivity are considered to be a cause of delirium. Polypharmacy, which is often present before admission to the ICU, especially in the elderly, plays a key role as a trigger. The knowledge and identification of risk factors for delirium is a precondition for the early and effective prevention of delirium. The aim is the pre-operative or pre-interventional optimization of modifiable risk factors. Early and effective prevention of delirium can improve clinical outcome, reduce mortality, and positively impact long-term functional outcome. Non-pharmacological measures are always the basis for the prevention of delirium: maintenance of the day-night rhythm, sleep promotion at night and stimulation during the day, involvement of relatives, the avoidance of dehydration and malnutrition, and others more. They are pharmacologically accompanied by an effective analgesia and a target and symptom-oriented sedation with well controllable, as little as possible delirogenic substances. Interdisciplinary and interprofessional cooperation is essential so that preventive concepts significantly reduce the risk of delirium, even in high-risk patients., Competing Interests: SG: Vortragshonorare und Reisekostenerstattung der Fa. Orion Pharma sowie Franz-Köhler-Chemie., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Interessenkonflikt: Stephan Braune hat Vortragshonorare der Firma Orion und der Firma Pfizer GmbH erhalten. Simone Gurlit hat Vortragshonorare der Firma Orion erhalten.

Due to increasing life expectancy, the number of elderly patients needing surgical care is increasing. Improvements in surgical techniques and anesthetic procedures offer the opportunity of surgical intervention even in frail patients. Delirium on admission to the hospital or in the perioperative setting is a common and often serious complication. Cognitive impairment is regarded as the main risk factor for delirium; unfortunately, under routine clinical conditions, these deficits often remain undetected. Postoperative delirium is associated with increased morbidity and mortality, as well as increased length of hospitalization, resulting in increased suffering and costs. The aim of the intervention presented here was to prevent delirium in a general hospital without a geriatric specialty department. Geriatric nurses became part of the team in the perioperative setting, giving psychological support and being a continuous companion to the patient and his/her proxies. Co-operation between all professions involved throughout hospitalization of the patient was emphasized. The low incidence of delirium in elderly surgical patients resulting from our efforts indicate that - for this setting in a general hospital - the strategy was effective for the prevention of delirium. Nowadays, geriatric nurses are an essential part of the perioperative team and delirium has lost much of its imminence.

A letter to the editor is presented in response to the article "Preventing Postoperative Delirium: A Prospective Intervention With Psychogeriatric Liaison on Surgical Wards in a General Hospital" by Torsten Kratz et al.