A curated collection of postoperative delirium and perioperative brain health references, research and podcasts.
Nathan N, Beyond Emergence: Understanding postoperative Cognitive Dysfunction (POCD) Anesthesia & Analgesia 08 2018; Vol. 127, Issue 2, p 323 doi: 10.1213/ANE.0000000000003598
Wanderer, JP, Rathmell JP, Preoperative Cognitive Dysfunction: It's More Common Than You Think. Anesthesiology 11 2017; Vol.127, A19. doi:10.1097/ALN.0000000000001918.
Centers for Medicare and Medicaid Services. Cognitive Assessment & Care Plan Services. Published 2021. Accessed August 17, 2021. https://www.cms.gov/cognitive
Kerry Dooley Young. Study Supports Etomidate for General Anesthesia in Older Patients. Medscape. Published August 17, 2022. Accessed August 29, 2022. https://www.medscape.com/viewarticle/979333#vp_1
Duprey MS, Devlin JW, Griffith JL, et al. Association between perioperative medication use and postoperative delirium and cognition in older adults undergoing elective noncardiac surgery. Anesth Analg. Published online February 24, 2022. doi: 10.1213/ANE.0000000000005959
Berger M, Browndyke JN, Cooter Wright M, et al. Postoperative changes in cognition and cerebrospinal fluid neurodegenerative disease biomarkers [published online ahead of print, 2022 Feb 1]. Ann Clin Transl Neurol. 2022;10.1002/acn3.51499. doi:10.1002/acn3.51499
Li T, Li J, Yuan L, et al. Effect of Regional vs General Anesthesia on Incidence of Postoperative Delirium in Older Patients Undergoing Hip Fracture Surgery: The RAGA Randomized Trial. JAMA. 2021;[published online ahead of print]. doi:10.1001/jama.2021.22647
Oberhaus J, Wang W, Mickle AM, et al. Evaluation of the 3-Minute Diagnostic Confusion Assessment Method for Identification of Postoperative Delirium in Older Patients. JAMA Netw Open. 2021;4(12):e2137267-e2137267. doi:10.1001/jamanetworkopen.2021.37267
Deeken F, Sánchez A, Rapp MA, et al. Outcomes of a Delirium Prevention Program in Older Persons After Elective Surgery: A Stepped-Wedge Cluster Randomized Clinical Trial. JAMA Surg. Published online December 15, 2021:e216370-e216370. doi:10.1001/jamasurg.2021.6370
Howell S, Nair S. Measuring frailty in the older surgical patient: the case for evidence synthesis. Br J Anaesth. 2021;126(4):763-767. doi:10.1016/j.bja.2021.01.002
McIsaac D, Fottinger A, Sucha E, McDonald B. Association of frailty with days alive at home after cardiac surgery: a population-based cohort study. Br J Anaesth. 2021;126(6):1103-1110. doi:10.1016/j.bja.2021.02.011
Darvall J, Story D. Heart, home, and frailty: new risk scores and outcomes for cardiac surgery patients. Br J Anaesth. 2021;126(6):1081-1084. doi:10.1016/j.bja.2021.02.022
Evered L, Chan M, Han R, et al. Anaesthetic depth and delirium after major surgery: a randomised clinical trial. Br J Anaesth. 2021;S0007-0912(21):00493-1. doi:10.1016/j.bja.2021.07.021
Linhardt F, Wachtendorf L, Wongtangman K, et al. Association of surgery type and duration of hospitalisation with the ability to live independently after surgery. Br J Anaesth. 2021;127(3):e87-e90. doi:10.1016/j.bja.2021.06.007
Noah A, Almghairbi D, Evley R, Moppett I. Preoperative inflammatory mediators and postoperative delirium: systematic review and meta-analysis. Br J Anaesth. 2021;127(3):424-434. doi:10.1016/j.bja.2021.04.033
Pedemonte J, Sun H, Franco-Garcia E, et al. Postoperative delirium mediates 180-day mortality in orthopaedic trauma patients. Br J Anaesth. 2021;127(1):102-109. doi:10.1016/j.bja.2021.03.033
Williams D, Ohnuma T, Haines K, et al. Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients. Br J Anaesth. 2021;126(3):730-737. doi:10.1016/j.bja.2020.12.026
Orser BA. Anesthesiology: Resetting Our Sights on Long-term Outcomes: The 2020 John W. Severinghaus Lecture on Translational Science. Anesthesiology. 2021;135(1):18-30. doi:10.1097/ALN.0000000000003798
Gregory SH, King CR, Ben Abdallah A, Kronzer A, Wildes TS. Abnormal preoperative cognitive screening in aged surgical patients: a retrospective cohort analysis. Br J Anaesth. 2021 Jan;126(1):230-237. doi: 10.1016/j.bja.2020.08.026. Epub 2020 Sep 14. PMID: 32943193; PMCID: PMC8014938.
Li Y, Li H, Li H, Zhao B, Guo X. Delirium in Older Patients after Combined Epidural– General Anesthesia or General Anesthesia for Major Surgery: A Randomized Trial. Anesthesiology. Published online 2021. doi:10.1097/ALN.0000000000003834
Li Y, Chen D, Wang H, Wang Z, Song F. Intravenous versus Volatile Anesthetic Effects on Postoperative Cognition in Elderly Patients Undergoing Laparoscopic Abdominal Surgery. Anesthesiology. 2021;134(381-94).
Magoon, Rohan. Impending cognitive and functional decline in COVID-19 survivors. Comment on Br J Anaesth 2021; 126: 44–7 [PDF] December 09, 2020 DOI:https://doi.org/10.1016/j.bja.2020.12.009
Belluck, Pam. They Had Mild Covid. Then Their Serious Symptoms Kicked In.[PDF] The New York Times March 23, 2021
Nalbandian, A., Sehgal, K., Gupta, A. et al. Post-acute COVID-19 syndrome[PDF] Nat Med (2021). https://doi.org/10.1038/s41591-021-01283-z
Rubin D, Peden C. Preoperative Frailty and Cognitive Dysfunction Assessment: When Will We Answer the Call to Action? Anesthesiology. December 2020, Vol. 133, 1164–1166. https://doi.org/10.1097/ALN.0000000000003579
Gaulton T, Cole D. COVID-19 and the Brain [PDF] ASA Monitor January 2021, Vol. 85, 25 https://doi.org/10.1097/01.ASM.0000725860.95171.aa
Baker H, Safavynia S, Evered L. The ‘third wave’: impending cognitive and functional decline in COVID-19 survivors [PDF] British Journal of Anaesthesia 126 (1): 44e47 (2021) doi: 10.1016/j.bja.2020.09.045
Peden C, Miller T, Deiner S, Eckenhoff R, Fleisher L. Improving perioperative brain health: an expert consensus review of key actions for the perioperative care team BJA January 2021; DOI:https://doi.org/10.1016/j.bja.2020.10.037
Evered et al. Preoperative Frailty Predicts Postoperative Neurocognitive Disorders After Total Hip Joint Replacement Surgery Anesthesia & Analgesia May 2020; DOI: 10.1213/ANE.0000000000004893
Wang et al. Dexmedetomidine Prevents Excessive γ-Aminobutyric Acid Type A Receptor Function after Anesthesia Anesthesiology. 2018, June; doi:10.1097/ALN.0000000000002311
Sprung J, Roberts RO, Weingarten TN, etal. Postoperative delirium in elderly patients is associated with subsequent cognitive impairment. Br J Anaesth. 2017;119(2):316-323.
Schenning KJ, Murchison CF, Mattek NC, Silbert LC, Kaye JA, Quinn JF. Surgery is associated with ventricular enlargement as well as cognitive and functional decline. Alzheimers Dement. 2016;12(5):590-597.
Hshieh TT, Saczynski J, Gou RY, et al; SAGES Study Group. Trajectory of functional recovery after postoperative delirium in elective surgery. Ann Surg. 2017;265(4):647-653.
Inouye SK, Marcantonio ER, Kosar CM, et al. The short-term and long-term relationship between delirium and cognitive trajectory in older surgical patients. Alzheimers Dement. 2016;12(7):766-775.
Evered LA, Silbert BS, Scott DA, Maruff P, Ames D. Prevalence of dementia 7.5 years after coronary artery bypass graft surgery. Anesthesiology. 2016;125(1):62-71
Lee HB, Oldham MA, Sieber FE, Oh ES. Impact of delirium after hip fracture surgery on one-year mortality in patients with or without dementia: a case of effect modification. Am J Geriatr Psychiatry. 2017 ;25(3):308-315.
Persistent neurologic symptoms and cognitive dysfunction in non‐hospitalized Covid‐19 “long haulers” [PDF]
Graham, E.L., Clark, J.R., Orban, Z.S., Lim, P.H., Szymanski, A.L., Taylor, C., DiBiase, R.M., Jia, D.T., Balabanov, R., Ho, S.U., Batra, A., Liotta, E.M. and Koralnik, I.J. (2021) Ann Clin Transl Neurol. https://doi.org/10.1002/acn3.51350
COVID Symptoms, Symptom Clusters, and Predictors for Becoming a Long-Hauler: Looking for Clarity in the Haze of the Pandemic [PDF]
Huang Y, Pinto M et al., medRxiv 2021.03.03.21252086; doi: https://doi.org/10.1101/2021.03.03.21252086
The Costs of Postoperative Delirium [PDF]
Katlic, Mark R.; Robinson, Thomas N. Published online February 24, 2021. JAMA Surgery doi:10.1001/jamasurg.2020.7257
One-Year Medicare Costs Associated With Delirium in Older Patients Undergoing Major Elective Surgery [PDF]
Gou, Ray Yun; Hshieh, Tammy T. et al. Published online February 24, 2021. JAMA Surg. doi:10.1001/jamasurg.2020.7260
Derivation, Validation, Sustained Performance, and Clinical Impact of an Electronic Medical Record–Based Perioperative Delirium Risk Stratification Tool [PDF]
Whitlock, Elizabeth L; Braehler, Matthias R.; Kaplan, Jennifer A.; Finlayson, Emily; Rogers, Stephanie E.; Douglas, Vanja; Donovan, Anne L.
An Implementation-Effectiveness Study of a Perioperative Delirium Prevention Initiative for Older Adults [PDF]
Donovan, Anne L.; Braehler, Matthias R.; Robinowitz, David L.; Lazar, Ann A.; Finlayson, Emily; Rogers, Stephanie; Douglas, Vanja C.; Whitlock, Elizabeth L.; Anesthesia Resident Quality Improvement Committee
Deiner et al. Adherence to recommended practices for perioperative anesthesia care for older adults among US anesthesiologists: results from the ASA Committee on Geriatric Anesthesia-Perioperative Brain Health Initiative ASA member survey Perioperative Medicine (2020) 9:6 doi.org/10.1186/s13741-020-0136-9
Perioperative Neurocognitive Disorder: State of the Preclinical Science [PDF]
Eckenhoff R, Maze M, et al. Perioperative Neurocognitive Disorder: State of the Preclinical Science [published online September 12, 2019] Anesthesiology. doi:10.1097/ALN.0000000000002956
Mahanna-Gabrielli E, Schenning JS, et al. State of the clinical science of perioperative brain health: report from the American Society of Anesthesiologists Brain Health Initiative Summit 2018 [published online August 19, 2019]. Br J Anaesth. doi: 10.1016/j.bja.2019.07.004
Sieber FE, Neufeld KJ, Gottschalk A, et al.; Effect of Depth of Sedation in Older Patients Undergoing Hip Fracture Repair on Postoperative Delirium,The STRIDE Randomized Clinical Trial, JAMA Surg., 8 2018, doi:10.1001/jamasurg.2018.2602.
Schulte PJ, Roberts RO, Knopman DS, et al.; Association between exposure to anaesthesia and surgery and long-term cognitive trajectories in older adults: report from the Mayo Clinic Study of Aging, British Journal of Anaesthesia, 8 2018, Vol. 121 (2), 398-405, doi:10.1016/j.bja.2018.05.060.
Postoperative Cognitive Dysfunction and Noncardiac Surgery
Evered, LA; Silbert, BS; Postoperative Cognitive Dysfunction and Noncardiac Surgery, Anesthesia & Analgesia, 8 2018, Vol. 127 (2), 496–505, doi: 10.1213/ANE.0000000000003514.
Culley DJ, Flaherty D, Fahey MC, Rudolph JL, Javedan H, et al. Poor Performance on a Preoperative Cognitive Screening Test Predicts Postoperative Complications in Older Orthopedic Surgical Patients, Anesthesiology 11 2017, Vol.127, 765-774. doi:10.1097/ALN.0000000000001859.
What This Article Tells Us That Is New
In a prospective clinical investigation of patients 65 yr or older without dementia having elective hip or knee replacement, screened preoperatively with the Mini-Cog, 24% were found to have probable cognitive impairment.
Patients with probable preoperative cognitive impairment, compared to those patients without, were more likely to be discharged to a place other than home, develop postoperative delirium, and have a longer hospital length of stay.
Preoperative cognitive screening of older surgical patients may be valuable for risk assessment and risk stratification in older surgical patients
Postoperative delirium as a target for surgical quality improvement
Berian, JR.; Zhou, L; Russell, MM, et al. Postoperative delirium as a target for surgical quality improvement [published online: July 24, 2017]Annals of Surgery. doi: 10.1097/SLA.0000000000002436.
This article used the new geriatric specific variables from the American College of Surgeons National Surgical Quality Improvement Program® (ACS NSQIP®) and showed large variability in delirium across hospitals (8.5 fold) with the strongest predictors as operation specific risk and preoperative cognitive impairment. These findings suggest that preoperative factors (procedure and underlying brain health) strongly influence whether a patient will develop delirium. However, adjusting for these risk factors some institutions appear to have a much higher incidence than others suggesting that postoperative environment may be important as well.
Read the full article (requires subscription)
The association between preoperative frailty and postoperative delirium after cardiac surgery
Brown CH 4th, Max L, LaFlam A, et al. The association between preoperative frailty and postoperative delirium after cardiac surgery. Anesthesia & Analgesia. 2016;123(2):430–435.
This prospective study screened patients for frailty prior to cardiac surgery and assessed for postoperative delirium. Frail patients had a much higher incidence of delirium (47.1%) as compared to non-frail patients (2.6%). The authors concluded that "frailty may identify patients who would benefit from delirium prevention strategies because of increased baseline risk for delirium."
Chen CC, Li HC, Liang JT, et al. Effect of a modified hospital elder life program on delirium and length of hospital stay in patients undergoing abdominal surgery - a cluster randomized clinical trial. JAMA Surg. 2017;152(9):827-834.
This study consisted of three protocols (the mHELP intervention) implemented daily by a dedicated nurse for orienting communication, oral and nutritional assistance and early mobilization for 377 older patients undergoing major intra-abdominal surgery. This was a clustered RCT.
For those patients who received the mHELP intervention the odds of delirium were reduced by 56% and length of stay by 2 days, compared with those patients who did not receive the intervention. The interventions are simple, applied to surgical patients, and the outcome’s impressive. The authors note that reliable implementation and delivery are key to success. The protocols are available within the Appendix in the paper.
The AWOL tool: derivation and validation of a delirium prediction rule
Douglas VC, Hessler CS, Dhaliwal G et al. The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med. 2013;8(9):493-499.
The AWOL tool is easily applied in a busy hospital floor or admission setting and takes less than two minutes. Derived and validated by Douglas et al AWOL is a simple risk prediction score to assess the risk of developing delirium in hospitalized adults.
The acronym AWOL is easy to remember, and stands for:
A: Age 80 years or greater
W: inability to spell the word "World" backwards
O: not fully Oriented to place
L: iLlness severity score assessed by a nurse - severity of moderately ill, severely ill, or moribund (as opposed to not ill or mildly ill)
More about AWOL:
Predicting delirium: are we there yet?
Evered LA. Predicting delirium: are we there yet? August 2017. Br J Anaesth. 2017;119(2):281-283.
This editorial appears in the August 2017 edition of the British Journal of Anaesthesia which has a whole section dedicated to articles on delirium. The editorial gives a good overview with some useful references.
The AWOL tool: derivation and validation of a delirium prediction rule
Douglas VC, Hessler CS, Dhaliwal G, et al. The AWOL tool: derivation and validation of a delirium prediction rule. J Hosp Med. 2013;8(9):493-499.
The AWOL prediction rule characterizes medical patients' risk for delirium at the time of hospital admission and could be used for clinical stratification and in trials of delirium prevention. Univariate analysis of the derivation study identified 10 variables significantly associated with delirium (see Table 2). Predictors of delirium included abnormal scores on 4 subtests of the MMSE, low score on the Mini‐Cog, living in an assisted living or skilled nursing facility, moderate to severe illness, old age, a past history of dementia, and hearing loss as assessed by the whisper test.
Managing and preventing postoperative delirium
Kuza C, Cobb JP, Managing and preventing postoperative delirium. Anesthesiology News: CMEZone The Frost Series #330. Released August 1, 2017. Expires July 31, 2018.
Postoperative delirium (POD) is a common adverse event in surgery, resulting in increased mortality, cost, and long-term cognitive and physical complications. After completion of this educational activity, the reader should be able to: Define postoperative delirium; Describe the two most common tools used to diagnose postoperative delirium; Identify risk factors for postoperative delirium; Recognize the long-term implications and outcomes of postoperative delirium; Review the treatment of postoperative delirium.
Case Studies
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