Postoperative Delirium in Patients Undergoing Total Joint Arthroplasty: A Systematic Review

doi:10.1016/j.arth.2015.03.012

The Journal of Arthroplasty

Volume 30, Issue 8, August 2015, Pages 1414-1417

https://doi.org/10.1016/j.arth.2015.03.012 Get rights and content

Abstract

We systematically reviewed the English-language literature to assess the incidence, risk factors and prevention strategies for postoperative delirium following total joint arthroplasty (TJA). A total of 10 studies were included in the final review, of which 3 (30%) were Level I studies, 6 were Level II (60%) studies and 1 (10%) was a Level III study. Incidence of postoperative delirium ranged from 5% to 14.3%. Pre-screening of patients was shown to reduce its incidence. Independent predictors include age, history of psychiatric illness, decreased functional status and decreased verbal memory.

Section snippets

Eligibility Criteria

Original studies that were conducted on the epidemiology, causative factors, risk profiles and prevention strategies in patients suffering from postoperative delirium following total joint arthroplasty were considered for this review. The American Psychiatric Association’s Diagnostic and Statistical Manual, 4th edition (DSM-IV) definition for delirium was adopted for this study. The DSM-IV lists four key features that characterize delirium [6]: (1) disturbance of consciousness with reduced

Incidence of Postoperative Delirium in Patients Undergoing TJA

The studies included in this systematic review (Table 1) suggest that the incidence of postoperative delirium in patients undergoing TJA of the hip or knee ranges from 0% to 10%. The 3 studies 3., 9., 13. that reported an incidence are prospective cohort studies. The respective incidences reported by these studies are 7%, 10% and 5%. 1 study utilized the mini-mental state examination (MMSE) [16] to determine delirium while 2 studies utilized the confusion assessment model (CAM) [17]. The study

Discussion

Orthopedic surgeons and healthcare institutions continue to strive to improve the efficiency of care associated with TJA as well as to reduce the incidence of perioperative morbidity and mortality. Advances in operative techniques and perioperative anesthetic care have made TJA a safe and reliable procedure to alleviate pain and restore function in patients with arthritis. However, there remain a group of patients, especially elderly ones, who remain at risk of developing postoperative delirium

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The impact of frailty as a critical mediator causing postoperative neurocognitive disorders in postoperative cardiac patients
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Frailty is prevalent in elderly cardiac patients and may be a critical predictor of post-operative neurocognitive disorders (PND). The aim of this review was to demonstrate the correlation of frailty with PND in postsurgical elder patients. A review of published literature and bibliometric analysis was undertaken. Electronic databases from 2009 to 2022 were searched to identify articles that evaluated the relationship between frailty and PND in aging populations. Demographic data, type of surgery performed, frailty measurement, and impact of frailty on PND were extracted from the selected studies. The quality of the studies and risk of bias were assessed by the Newcastle-Ottawa Quality Assessment Scale, and the included articles were assessed as medium to high quality. Eighty-one studies were selected for the Bibliometric review in terms of research trends and hotpots. Additionally, 35 observational studies (prospective and retrospective cohorts) were selected for this review. The mean age ranged from 63 to 84 years and included patients undergoing cardiac, orthopedic, and other surgeries who had cardiac symptoms. Regardless of how frailty was measured, the strongest evidence in terms of numbers of studies, consistency of results, and study quality was for associations between frailty and PND. This analysis found a steadily growing focus on frailty and PND research in cardiac and other patients. The observational studies account for the majority of this area, and frailty occurred in the older cardiac patients over 60 years of age, and pre-screening of frailty can be predictive of PND and mortality.
The impact of regional versus general anesthesia on postoperative neurocognitive outcomes in elderly patients undergoing hip fracture surgery: A systematic review and meta-analysis
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Randomized trials have shown conflicting results regarding differences in outcomes according to anesthesia type on the prevalence of postoperative delirium (POD) or postoperative cognitive dysfunction (POCD) in hip surgery patients. The aim of this Meta analysis is to compare the effect of general and regional anesthesia in older patients undergoing hip fracture surgery.
A literature search for meta-analysis was performed using Pubmed, The Cochrane Library, Embase and Web of Science citation index for randomized controlled trials (RCTs) to compare the regional anesthesia (RA) to general anesthesia (GA) for postoperative outcomes in elderly undergoing hip fracture surgery till June 2022. The primary outcomes were the incidence of POD or POCD at 24 h, 3 days and 7 days postoperatively. The secondary outcomes were 30 days mortality rate and other adverse events. The risk of bias was assessed using the Cochrane methodology.
Eight studies including 3555 elderly patients over 65 years old showed that there was no significant difference in the prevalence of POD or POCD between RA and GA at 24 h [OR 0.73; 95% coincidence interval (CI) 0.19, 2.71, I² = 53%; n = 452; P = 0.63], at 3 days [OR 1.03; 95% CI 0.79, 1.35, I² = 0%; n = 1362; P = 0.82], at 7 days [OR 0.79; 95% CI 0.41, 1.52, I² = 51%; n = 1336; P = 0.47], respectively. No significant differences were observed in the incidence of other adverse events.
No significant difference was found in the incidence of cognitive dysfunction after either general or regional anesthesia in elderly patients. Our finding of similar outcomes at 24 h, 3 days and 7 days postoperatively with either technique suggests that anesthesia choices for hip-fracture surgery may be based on the individual characteristics of each patient rather than on anticipated differences in clinical outcomes.
Incidence and risk factors of postoperative delirium following total knee arthroplasty: A retrospective Nationwide Inpatient Sample database study
2022, Knee
Citation Excerpt :
However, quite a few postoperative patients suffer from postoperative complications. Postoperative delirium is one of the common complications after TKA, resulting in heavy burdens on individuals and society [1]. Delirium is an acute and fluctuating alteration of mental state characterized by the disturbance of consciousness, cognitive function, or perception.
Postoperative delirium is a common complication following major surgeries, causing a variety of adverse effects. However, the incidence and risk factors of delirium after primary total knee arthroplasty (TKA) has not been well studied using a large-scale national database.
A retrospective database analysis was performed based on Nationwide Inpatient Sample (NIS) from 2005-2014. Patients who underwent primary TKA were included. Patient demographics, comorbidities, length of stay (LOS), total charges, type of payer, in-hospital mortality, and perioperative complications were evaluated.
A total of 1,228,879 TKAs were obtained from the NIS database. The general incidence of delirium after TKA was 1.00%, which peaked in the year 2008. Patients with delirium after TKA presented increased comorbidities, LOS, hospital charges, usage of medicare, and in-hospital mortality (P < 0.0001). Delirium following TKA was associated with medical complications during hospitalization including acute renal failure, acute myocardial infarction, pneumonia, pulmonary embolism, stroke, and urinary tract infection. Risk factors of postoperative delirium included advanced age, neurological disorders, alcohol and drug abuse, depression, psychoses, fluid and electrolyte disorders, diabetes, weight loss, deficiency and chronic blood loss anemia, coagulopathy, congestive heart failure, chronic pulmonary disease, pulmonary circulation disorders, peripheral vascular disorders, chronic renal failure, and teaching hospital. Notably, neurological disorders were found to have the strongest association with the occurrence of postoperative delirium.
A relatively low incidence of delirium after TKA was identified. It is of benefit to study risk factors of postoperative delirium to ensure the appropriate management and moderate its consequences.
Postoperative delirium following total joint arthroplasties in a multi-ethnic population – A prospective observational study
2021, Knee
Citation Excerpt :
While patients in our study did not undergo fast-rack surgery, the opioid-reducing protocol and early mobilization strategies adopted in our institution is in line with the fast-track methodology. As use of opioids is known to be an independent risk factor for POD, the perioperative patient management strategies in our instituted could have mitigated the overall risk [10]. The modality of anaesthesia is another modifiable risk factor that has also been associated with the development of POD [10,29,35].
Postoperative delirium (POD) is a cause of poorer patient outcomes following total joint arthroplasties (TJA). However, it often goes undiagnosed. Although various risk factors have been documented, study heterogeneity leads to poor understanding within a South East Asian population. This study aims to evaluate POD within this demographic and elucidate its risk factors.
This was a single-centre prospective observational study comprising 462 patients. Inclusion criteria was patients 65–90 years old undergoing elective TJA. Exclusion criteria was patients unable to personally provide consent for TJA. Preoperative, intraoperative, and postoperative data was recorded to analyse treatment pathway factors. Patients were assessed for POD twice daily for 3 days after TJA using the Confusion Assessment Method (CAM).
Mean age of the study cohort was 72 ± 5 years; 70.1% were female; and mean MMSE score preoperatively was 27.3 ± 3.3. 419 patients underwent total knee arthroplasty (TKA) and 43 patients underwent total hip arthroplasty (THA). 164 patients received general anaesthesia, and 298 patients received regional anaesthesia. Overall, 0% (0/462) of patients tested positive for POD at any postoperative timepoint. While various CAM components were met, no patients were positive for the complete requisite criteria for POD diagnosis.
We report zero incidence of POD in 462 patients who underwent elective TJA in our institution. We believe that our streamlined care process including pre-operative assessment, patient-specific anaesthesia regime as well as a strictly administered inpatient clinical care pathway with opioid-reducing strategy and early mobilization are protective factors against POD.
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: No author associated with this paper has disclosed any potential or pertinent conflicts which may be perceived to have impending conflict with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2015.03.012.

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Postoperative Delirium in Patients Undergoing Total Joint Arthroplasty: A Systematic Review

Abstract

Section snippets

Eligibility Criteria

Incidence of Postoperative Delirium in Patients Undergoing TJA

Discussion

Arch Gerontol Geriatr

Knee

Br J Anaesth

Psychosomatics

J Arthroplasty

J Arthroplasty

J Psychiatr Res

Mortality after total hip replacement surgery: a systematic review

Bone Joint Res

Changes in mortality patterns following total hip or knee arthroplasty over the past two decades: a nationwide cohort study

Arthritis Rheum

Review articles: postoperative delirium: acute change with long-term implications

Anesth Analg

Diagnostic and Statistical Manual

A randomized, double-blinded, placebo-controlled trial of donepezil hydrochloride (Aricept) for reducing the incidence of postoperative delirium after elective total hip replacement

Int J Geriatr Psychiatry

Cognitive and functional predictors and sequelae of postoperative delirium in elderly patients undergoing elective joint arthroplasty

Anesth Analg