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BackgroundVolatile Anaesthetics (VAs) may be associated with postoperative delirium (POD). However, to date, the effects of VAs on POD are not completely understood. The objective of this study was to investigate the incidence of POD in different VA groups.MethodsA secondary analysis was conducted using a database created from prospective cohort studies in patients who underwent elective major noncardiac surgery. Patients who received general anaesthesia with desflurane, isoflurane, or sevoflurane were included in the study. POD occurring on either of the first two postoperative days was measured using the Confusion Assessment Method.ResultsFive hundred and thirty-two patients were included in this study, with a mean age of 73.5 ± 6.0 years (range, 65-96 years). The overall incidence of POD on either postoperative day 1 or 2 was 41%. A higher incidence of POD was noted in the desflurane group compared with the isoflurane group (Odds Ratio = 3.35, 95% CI = 1.54-7.28). The incidence of POD between the sevoflurane and isoflurane or desflurane group was not statistically significant.ConclusionEach VA may have different effects on postoperative cognition. Further studies using a prospective randomized approach will be necessary to discern whether anaesthetic type or management affects the occurrence of postoperative delirium.

BackgroundPostoperative delirium is prevalent in older patients and associated with worse outcomes. Recent data in animal studies demonstrate increases in inflammatory markers in plasma and cerebrospinal fluid (CSF) even after aseptic surgery, suggesting that inflammation of the central nervous system may be part of the pathogenesis of postoperative cognitive changes. We investigated the hypothesis that neuroinflammation was an important cause for postoperative delirium and cognitive dysfunction after major non-cardiac surgery.MethodsAfter Institutional Review Board approval and informed consent, we recruited patients undergoing major knee surgery who received spinal anesthesia and femoral nerve block with intravenous sedation. All patients had an indwelling spinal catheter placed at the time of spinal anesthesia that was left in place for up to 24 h. Plasma and CSF samples were collected preoperatively and at 3, 6, and 18 h postoperatively. Cytokine levels were measured using ELISA and Luminex. Postoperative delirium was determined using the confusion assessment method, and cognitive dysfunction was measured using validated cognitive tests (word list, verbal fluency test, digit symbol test).ResultsTen patients with complete datasets were included. One patient developed postoperative delirium, and six patients developed postoperative cognitive dysfunction. Postoperatively, at different time points, statistically significant changes compared to baseline were present in IL-5, IL-6, I-8, IL-10, monocyte chemotactic protein (MCP)-1, macrophage inflammatory protein (MIP)-1α, IL-6/IL-10, and receptor for advanced glycation end products in plasma and in IFN-γ, IL-6, IL-8, IL-10, MCP-1, MIP-1α, MIP-1β, IL-8/IL-10, and TNF-α in CSF.ConclusionsSubstantial pro- and anti-inflammatory activity in the central neural system after surgery was found. If confirmed by larger studies, persistent changes in cytokine levels may serve as biomarkers for novel clinical trials.

Study objectivesTo describe preoperative and postoperative sleep disruption and its relationship to postoperative delirium.DesignProspective cohort study with 6 time points (3 nights pre-hospitalization and 3 nights post-surgery).SettingUniversity medical center.PatientsThe sample consisted of 50 English-speaking patients ≥ 40 years of age scheduled for major non-cardiac surgery, with an anticipated hospital stay ≥ 3 days.InterventionsNone.Measurements and resultsSleep was measured before and after surgery for a total of 6 days using a wrist actigraph to quantify movement in a continuous fashion. Postoperative delirium was measured by a structured interview using the Confusion Assessment Method. Sleep variables for patients with (n = 7) and without (n = 43) postoperative delirium were compared using the unpaired Student t-tests or χ(2) tests. Repeated measures analysis of variance for the 6 days was used to examine within-subject changes over time and between group differences. The mean age of the patients was 66 ± 11 years (range 43-91 years), and it was not associated with sleep variables or postoperative delirium. The incidence of postoperative delirium observed during any of the 3 postoperative days was 14%. For the 7 patients who subsequently developed postoperative delirium, wake after sleep onset (WASO) as a percentage of total sleep time was significantly higher (44% ± 22%) during the night before surgery compared to the patients who did not subsequently developed delirium (21% ± 20%, p = 0.012). This sleep disruption continued postoperatively, and to a greater extent, for the first 2 nights after surgery. Patients with WASO < 10% did not experience postoperative delirium. Self-reported sleep disturbance did not differ between patients with vs. without postoperative delirium.ConclusionsIn this pilot study of adults over 40 years of age, sleep disruption was more severe before surgery in the patients who experienced postoperative delirium. A future larger study is necessary to confirm our results and determine if poor sleep is associated with delirium in larger samples and what specific sleep problems best predict postoperative delirium in older surgical patients.

Objectives: Prior studies reported incidence of hypoactive and hyperactive subtypes of postoperative delirium, but did not consider cognitive symptoms of delirium which are highlighted in the DSM‐5 criteria for delirium. This study aims to address this gap in the literature by classifying cases of delirium according to their constellation of cognitive and motoric symptoms of delirium using a statistical technique called Latent Class Analysis (LCA). Methods: Data were from five independent study cohorts (N = 1968) of patients who underwent elective spine, knee/hip, or elective gastrointestinal and thoracic procedures, between 2001 and 2017. Assessments of delirium symptoms were conducted using the long form of the Confusion Assessment Method (CAM) pre‐ and post‐surgery. Latent class analyses of CAM data from the first 2 days after surgery were conducted to determine subtypes of delirium based on patterns of cognitive and motoric symptoms of delirium. We also determined perioperative patient characteristics associated with each latent class of delirium and assessed whether the length of delirium for each of the patterns of delirium symptoms identified by the latent class analysis. Results: The latent class model from postoperative day 1 revealed three distinct patterns of delirium symptoms. One pattern of symptoms, denoted as the Hyperalert class, included patients whose predominant symptoms were being hyperalert or overly sensitive to environmental stimuli and having a low level of motor activity. Another pattern of symptoms, denoted as the Hypoalert class, included patients whose predominant symptom was being hypoalert (lethargic or drowsy). A third pattern of symptoms, denoted as the Cognitive Changes class, included patients who experienced new onset of disorganized thinking, memory impairment, and disorientation. Among 352 patients who met CAM criteria for delirium on postoperative day 1, 34% had symptoms that fit within the Hyperalert latent class, 39% had symptoms that fit within the Hypoalert latent class, and 27% had symptoms that fit within the Cognitive Changes latent class. Similar findings were found when latent class analysis was applied to those who met CAM criteria for delirium on postoperative day 2. Multinomial regression analyses revealed that ASA class, surgery type, and preoperative cognitive status as measured by the Telephone Interview for Cognitive Status (TICS) scores were associated with class membership. Length of delirium differed between the latent classes with the Cognitive Changes latent class having a longer duration compared to the other two classes. Conclusions: Older elective surgery patients who did not have acute events or illnesses or a diagnosis of dementia prior to surgery displayed varying symptoms of delirium after surgery. Compared to prior studies that described hypoactive and hyperactive subtypes of delirium, we identified a novel subtype of delirium that reflects cognitive symptoms of delirium. The three subtypes of delirium reveal distinct patterns of delirium symptoms which provide insight into varying risks and care needs of patients with delirium, indicating the necessity of future research on reducing risk for cognitive symptoms of delirium. Key Points: Although hypoactive and hyperactive motoric subtypes of postoperative delirium have been identified in literature, prior studies have not considered cognitive symptoms of delirium which are highlighted by the DSM‐5 criteria for delirium.Among elective surgery patients who did not have a diagnosis of dementia, and were not experiencing acute illnesses, events, or changes in mental status at hospital admission, we found that more than 40% of patients experienced cognitive symptoms of delirium using the long‐form of the Confusion Assessment Method that comprehensively assesses cognitive and motoric symptoms of delirium and its range of symptoms.Latent class analysis revealed three patterns of symptoms: patients in the first latent class predominantly displayed a hyperalert level of consciousness; patients in the second latent class predominantly displayed a hypoalert level of consciousness; and patients in the third latent class predominately displayed acute onset of disorganized thinking, disorientation, and memory impairment.Compared to those in the Hypoalert latent class, those in the Hyperalert latent class were more likely to have general surgery and have lower preoperative mental status scores, and those in the acute onset of cognitive symptoms latent class (Cognitive Changes) were more likely to have lower preoperative mental status scores. [ABSTRACT FROM AUTHOR]

ObjectivesTo investigate whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on the development of postoperative delirium.DesignProspective cohort study.SettingUniversity medical center.ParticipantsPatients 65 years of age or older scheduled for major noncardiac surgery.MeasurementsA structured interview was conducted preoperatively and postoperatively to determine the presence of delirium, defined using the Confusion Assessment Method. We first developed a prediction model to determine which patients were at high versus low risk for the development of delirium based on preoperative patient data. We then computed a logistic regression model to determine whether preoperative risk for delirium moderates the effect of postoperative pain and opioids on incident delirium.ResultsOf 581 patients, 40% developed delirium on days 1 or 2 after surgery. Independent preoperative predictors of postoperative delirium included lower cognitive status, a history of central nervous system disease, high surgical risk, and major spine and joint arthroplasty surgery. Compared with the patients at low preoperative risk for developing delirium, the relative risk for postoperative delirium for those in the high preoperative risk group was 2.38 (95% confidence interval: 1.67-3.40). A significant three-way interaction indicates that preoperative risk for delirium significantly moderated the effect of postoperative pain and opioid use on the development of delirium. Among patients at high preoperative risk for development of delirium who also had high postoperative pain and received high opioid doses, the incidence of delirium was 72%, compared with 20% among patients with low preoperative risk, low postoperative pain, and those who received low opioid doses.ConclusionsHigh levels of postoperative pain and using high opioid doses increased risk for postoperative delirium for all patients. The highest incidence of delirium was among patients who had high preoperative risk for delirium and also had high postoperative pain and used high opioid doses.

ObjectivesTo determine whether intraoperative blood transfusion, a known trigger and amplifier of inflammation, is an independent risk factor for early postoperative delirium (POD), an acute state of confusion with fluctuating consciousness and inattention after surgery, in older adults undergoing surgery.DesignSecondary analysis using a database created for a prospective cognitive outcomes study.SettingUniversity hospital.ParticipantsFour hundred seventy-two individuals aged 65 and older undergoing major noncardiac surgery.MeasurementsPerioperative data were examined for association with POD on the first postoperative day. Multivariable logistic regression analysis was conducted to determine whether intraoperative blood transfusion independently predicts POD after adjusting for covariates known to be associated with onset of delirium and blood transfusions.ResultsOne hundred thirty-seven individuals (29%) developed delirium on the first postoperative day. The multivariable logistic regression model identified age, sex, history of central nervous system disorder, preoperative cognitive dysfunction, and pain, as well as blood transfusions, as independent risk factors for POD. Intraoperative administration of more than 1,000 mL of red blood cells (RBCs) was the strongest predictor of POD on the first postoperative day (odds ratio = 3.68; 95% confidence interval = 1.32–10.94; P < .001).ConclusionIntraoperative blood transfusion of more than 1,000 mL of RBCs increases the risk of delirium on the first postoperative day in older adults undergoing noncardiac surgery.

Objective to determine whether incident postoperative delirium in elective older surgical patient was associated with increased risk for mortality, controlling for covariates of 5-year mortality. Design secondary analysis of prospective cohort studies. Setting academic Medical Center. Subjects patients ≥65 years of age undergoing elective non-cardiac surgery. Outcomes postoperative assessments of delirium measured using the Confusion Assessment Method (CAM), mortality within 5 years of the index surgery was determined from National Death Index records. Results postoperative delirium occurred in 332/1,315 patients (25%). Five years after surgery, 175 patients (13.3%) were deceased. Older age was associated with an increased odds of mortality [odds ratio (OR) 1.90, 95% confidence interval (CI) 1.20–2.70] for those aged 70–79 years compared to those aged <70 years, and OR 3.29, 95% CI 2.14–5.06 for those aged >80 years. Other variables associated with 5-year mortality on bi-variate analyses were white race, self-rated functional status, lower preoperative cognitive status, higher risk score as measured by the American Society of Anesthesiologists (ASA) classification, higher surgical risk score, history of congestive heart failure, myocardial infarction, renal disease, cancer, peripheral vascular disease and postoperative delirium. However, postoperative delirium was not associated with 5-year mortality on multi-variate logistic regression (OR 1.18, 95% CI 0.85–1.65). Conclusions our results showed that delirium was not associated with 5-year mortality in elective surgical patients after consideration of co-variates of mortality. Our results suggest the importance of accounting for known preoperative risks for mortality when investigating the relationship between delirium and long-term mortality. [ABSTRACT FROM AUTHOR]

The article reports on the result of the study which assessed whether postoperative delirium affects the administration of patient-controlled analgesia (PCA) in older patients. The study was conducted on 335 older patients undergoing noncardic surgery and utilized PCA. Delirium in patients was measured through the Confusion Assessment Method. It was found that postoperative delirium did not limit the administration of PCA. Patients with delirium used the analgesia for 24 hours compared to those patients who were not suffering from delirium.

Background. Delirium is common in older surgical patients and predicts negative health outcomes. Whether depressive symptoms are prevalent and predict the development of postoperative delirium in elderly surgical patients has not been investigated. Our study aimed to examine the prevalence and prognostic importance of preoperative depressive symptoms in older surgical patients. Methods. Patients al least 65 years of age who were scheduled for major noncardiac surgery were recruited. Preoperatively, patients were screened for symptoms of depression using the 15-point Geriatric Depression Scale (GDS). Postoperative delirium was measured using the Confusion Assessment Method. The associations between covariates and preoperative depression, and postoperative delirium were determined by multivariate logistic regression. Results. In the 219 patients studied, the mean age was 73.6 ± 6 years, 12% of patients reported six or more depressive symptoms, and 32% reported three to five depressive symptoms. By multivariate logistic regression, patient characteristics associated with six or more symptoms of depression included < 12 years of education, moderate to severe limitation in functional status, and drinking more than two alcoholic beverages per day. Postoperatively, 46% of patients developed delirium. Patients with a greater number of preoperative depressive symptoms were more likely to develop postoperative delirium (p = .048) and experience a longer duration of postoperative delirium (p = .027). Even after adjusting for covariates associated with depression and postoperative delirium--including age, educational level, functional status, and preoperative alcohol use patients with more than six preoperative depressive symptoms were still significantly more likely to have a longer duration of postoperative delirium than did those patients with fewer than two depressive symptoms (odds ratio = 2.69, confidence interval = 1.04-6.93). Conclusion. Preoperative screening for the presence of depressive symptoms can be performed easily in elderly patients, and yields useful prognostic information relating to postoperative delirium. [ABSTRACT FROM AUTHOR]

To describe the association between preoperative sleep disruption and postoperative delirium. Prospective cohort study with six time points (3 nights pre-hospitalization and 3 nights post-surgery). The sample included 180 English-speaking patients ≥65 years old scheduled for major non-cardiac surgery and anticipated minimum hospital stay of 3 days. Six days of wrist actigraphy recorded continuous movement to estimate wake and sleep minutes during the night from 22:00 to 05:59. Postoperative delirium was measured by a structured interview using the Confusion Assessment Method. Sleep variables for patients with (n = 32) and without (n = 148) postoperative delirium were compared using multivariate logistic regression. Participants had a mean age of 72 ± 5 years (range 65–95 years). The incidence of postoperative delirium during any of the three postoperative days was 17.8%. Postoperative delirium was significantly associated with surgery duration (OR = 1.49, 95% CI 1.24–1.83) and sleep loss >15% on the night before surgery (OR = 2.64, 95% CI 1.10–6.62). Preoperative symptoms of pain, anxiety and depression were unrelated to preoperative sleep loss. In this study of adults ≥65 years of age, short sleep duration was more severe preoperatively in the patients who experienced postoperative delirium as evidenced by sleep loss >15% of their normal night's sleep. However, we were unable to identify potential reasons for this sleep loss. Further investigation should include additional factors that may be associated with preoperative sleep loss to inform potential intervention strategies to mitigate preoperative sleep loss and reduce risk of postoperative delirium. • Sleep loss >15% during the night before surgery compared to prior two nights was associated with postoperative delirium even after controlling for demographic characteristics. • Preoperative symptoms of pain, anxiety and depression were unrelated to preoperative sleep loss. • Postoperative delirium may be minimized by addressing short sleep duration the night before surgery to avoid subsequent adverse outcomes such as admission to intensive care or prolonged length of hospital stay. [ABSTRACT FROM AUTHOR]