Introduction
Materials and methods
Search strategy
Study selection
Data extraction
Quality scoring of included trials
Item | Score | Criteria | |
---|---|---|---|
2 | Randomization is described and adequate (random numbers, computer generated, etc.) | ||
Randomization
| 1 | Randomization is described | |
0 | No or inappropriate randomization | ||
Allocation
| 2 | Allocation concealment is described and adequate (sequentially numbered opaque sealed envelopes, central randomization, etc.) | |
concealment
| 1 | Allocation concealment is described | |
Adapted Jadad score
| 0 | No or inappropriate allocation concealment | |
Intervention
| 2 | Blinding is described and adequate | |
blinding
| 1 | Blinding is described | |
0 | No or inappropriate blinding | ||
Withdrawal or
| 1 | Withdrawals and dropouts are described | |
dropouts
| 0 | Withdrawals or dropouts are not described | |
Intention-to-treat
| 1 | ITT analysis is used | |
(ITT) analysis
| 0 | ITT analysis is not used | |
Similar groups at baseline
| 1 | ||
0 | Delirium-related factors are not screened or different | ||
Delirium specific score
|
Delirium assessor blinding
| 1 | Delirium assessor is blinded to the interventions |
Delirium assessor is not blinded to the interventions | |||
2 | |||
Delirium follow-up
| 1 | Frequency: ≥ 1/day since POD 1 and duration: POD 1-3 | |
0 | Frequency: < 1/day or duration < 3 days since POD 1 |
Data analysis
Results
Study selection
Study characteristics
Subcategory | Study | Definition delirium | Evaluation timing (d) | Surgery type | Intervention (I1 vs. I2) | Gender (F/M) | Age (y) | Score | Incidence (n/total) (%) | P value | Delirium duration or severity | Hospital stay (d) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Controlled hypotension
| Williams-Russo, 1999 [23] | DSM- III | POD 1-7 or discharge | Orthopedic | MAP 45-55 vs. MAP 55-70 mmHg | I1: 51/66 I2: 65/53 | I1: 72 ± 7 I2: 72 ± 8 | 10 | I1: 10/117 (8.5%) I2: 5/118 (4.2%) | 0.177 | N/A | |
Berggren, 1987 [17] | DSM- III | POD 1,7 | Orthopedic | Neuraxial (epidural) vs. general anesthesia (halothane) | I1: 22/7 I2: 24/4 | I1: 78 ± 8 I2: 77 ± 7 | 5 | I1: 11/26 (42.3%) I2: 9/26 (34.6%) | 0.569 | N/A, NS | ||
Anesthesia type (neuraxial or general anesthesia)
| Williams-Russo, 1995 [20] | DSM- III | POD 1-7 | Orthopedic | Neuraxial (epidural) vs. general anesthesia (isoflurane) | I1: 71/63 I2: 70/58 | I1: 69 I2: 69 | 9 | I1: 16/134 (11.9%) I2: 12/128 (9.4%) | 0.502 | I1: 12.7 ± 5.3 I2: 12.7 ± 4.3 | |
Kudoh, 2004 [27] | CAM | POD 1-7 | Orthopedic | Neuraxial (epidural) vs. general anesthesia (propofol) | I1: 69/6 I2: 66/9 | I1: 76 ± 4 I2: 75 ± 4 | 8 | I1: 5/75 (6.7%) I2: 12/75 (16%) | 0.070 | N/A | ||
Papaioannou, 2005 [31] | DSM-III | POD 1-3 | Abdominal | Neuraxial (some patients used propofol for sedation) vs. general anesthesia | I1: 10/18 I2: 7/12 | > 60 | 7 | I1: 6/28 (21.4%) I2: 3/19 (15.8%) | 0.720 | N/A | ||
Sedation depth during spinal anesthesia
| Sieber, 2010 [47] | CAM | POD 1-discharge | Orthopedic | Deep sedation (BIS ≈ 50) vs. light sedation (BIS ≥ 80) | I1: 43/14 I2: 40/17 | I1: 82 ± 7 I2: 81 ± 8 | 9 | I1: 23/57 (40.4%) I2: 11/57 (19.3%) |
0.014
|
Duration (
P
= 0.01):
I1: 1.4 ± 4.0 days I2: 0.5 ± 1.5 days
Duration in patients with delirium (
P
= 0.77):
I1: 3.4 ± 5.7 days I2: 2.8 ± 2.3 days | I1: 4.5 ± 2.3 I2: 4.7 ± 3.1 |
Nishikawa, 2004 [28] | DSM-III, DRS | POD 1-3 | Abdominal | Epidural anesthesia/propofol vs. epidural anesthesia/sevoflurane | I1: 12/13 I2: 13/12 | I1: 71 ± 8 I2: 71 ± 7 | 7 | I1: 4/25 (16%) I2: 0/25 (0) | 0.110 |
Severity based on DRS (
P
= 0.002):
I1: 6 ± 3 I2: 2 ± 1 | N/A | |
Anesthesia (anesthetics)
| Hudetz, 2009 [40] | DSM-IV | POD 1-5 | Cardiovascular | Additional ketamine (0.5 mg/kg, iv, single bolus) vs. standard | N/A | I1: 68 ± 8 I2: 60 ± 8 | 8 | I1: 1/29 (3.4%) I2: 9/29 (31.0%) |
0.012
| I1: 8 ± 4 I2: 7 ± 3 | |
Royse, 2011 [51] | CAM | POD 1 | Cardiovascular | propofol vs. desflurane | I1: 9/80 I2: 18/73 | I1: 64 ± 11 I2: 62 ± 10 | 8 | I1: 7/89 (7.9%) I2: 12/92 (13.0%) | 0.245 | I1: 7 ± 2 I2: 6 ± 2 | ||
Leung, 2006 [34] | CAM | POD 1-2 | Non-cardiovascular | Additional N2O vs. standard | I1: 62/52 I2: 51/63 | I1: 74 ± 6 I2: 74 ± 6 | 6 | I1: 44/105 (41.9%) I2: 46/105 (43.8%) | 0.780 | I1: 5.4 ± 3.5 I2: 4.8 ± 2.9 | ||
Postoperative analgesia (epidural or intravenous analgesia)
| Williams-Russo, 1992 [19] | DSM- III | POD 1-7 | Orthopedic | Epidural analgesia vs. Intravenous analgesia | N/A | 68 ± 7 | 7 | I1: 10/26 (38.5%) I2: 11/25 (44%) | 0.688 | N/A | |
Mann, 2000 [24] | DSM-III | POD 1- discharge | Abdominal | Epidural analgesia vs. Intravenous analgesia | I1: 15/20 I2: 17/18 | I1: 76 ± 6 I2: 77 ± 5 | 8 | I1: 8/31 (25.8%) I2: 8/33 (24.2%) | 0.885 | I1: 10.5 ± 5 I2: 11.5 ± 6 | ||
Beaussier, 2006 [32] | CAM | POD 1- discharge | Abdominal | Epidural analgesia vs. Intravenous analgesia | I1: 11/15 I2: 14/12 | I1: 78 ± 5 I2: 77 ± 5 | 9 | I1: 9/26 (34.6%) I2: 10/26 (38.5%) | 0.773 | I1: 7.9 ± 2 I2: 8.4 ± 1.7 | ||
Postoperative analgesia (additional regional analgesia or standard treatment)
| Mouzopoulos, 2009 [43] | DSM-IV, CAM, DRS | POD 1- discharge | Orthopedic | Additional fascia iliaca compartment block (0.25% bupivacaine, 0.3 mL/kg) vs. standard treatment | I1: 78/24 I2: 76/29 | I1: 72 ± 4 I2: 73 ± 4 | 7 | I1: 11/102 (10.8%) I2: 25/105 (23.8%) |
< 0.001
|
Duration (
P
< 0.001):
I1: 5.22 ± 4.28 days I2: 10.97 ± 7.16 days
Severity based on DRS (
P
< 0.001):
I1: 14.34 ± 3.6 I2: 18.61 ± 3.4 | N/A |
Postoperative analgesia (morphine or placebo)
| Musclow, 2012 [53] | NEECHAM | POD 1- discharge | Orthopedic | Morphine (30 mg, bid, po) (POD1-3) vs. placebo | I1: 78/24 I2: 76/29 | I1: 67 ± 4 I2: 64 ± 11 | 11 | I1: 10/97 (10.3%) I2: 3/93 (3.2%) | 0.082 |
Severity based on NEECHAM (
P
= 0.02):
I1: 28.70 ± 1.82 I2: 29.14 ± 0.61 | N/A |
Postoperative sedation (alpha-2 adrenergic receptor agonists or other sedatives)
| Maldonado, 2009 [41] | DSM-IV | POD 1-3 | Cardiovascular | Dexmedetomidine (loading dose: 0.4 μg/kg, maintenance drip of 0.2-0.7 μg/kg/hour) vs. propofol (25-75 μg/kg/min) vs. midazolam (0.5-2 mg/hour) | I1: 14/26 I2: 16/22 I3: 13/27 | I1: 55 ± 16 I2: 58 ± 18 I3: 60 ± 16 | 8 | I1: 4/40 (10%) I2: 16/36 (44.4%) I3: 17/40 (42.5%) |
< 0.001
|
Duration in patients with delirium (
P
= 0.82):
I1: 2.0 ± 0 days I2: 3.0 ± 3.1 days I3: 5.4 ± 6.6 days | I1: 7.1 ± 1.9 I2: 8.2 ± 3.8 I3: 8.9 ± 4.7 |
Shehabi, 2009 [44] | CAM-ICU | POD 1-5 | Cardiovascular | Dexmedetomidine (0.1-0.7 μg/kg/hour) vs. morphine (10-70 μg/kg/hour) | I1: 38/114 I2: 36/111 | I1: 72 ± 8 I2: 71 ± 8 | 11 | I1: 13/152 (8.6%) I2: 22/147 (15.0%) |
0.031
|
Duration (
P
= 0.032):
I1: 2 ± 4 days I2: 5 ± 8 days | I1: 8 ± 3 I2: 8 ± 3 | |
Rubino, 2010 [46] | DSM-IV, DDS | 30 minutes after weaning | Cardiovascular | Additional clonidine (loading dose: 0.5 μg/kg, maintenance drip of 1-2 μg/kg/hour) vs. standard | I2: 5/10 I2: 7/8 | I1: 64 ± 9 I2: 61 ± 6 | 8 | I1: 6/15 (40%) I2: 5/15 (30%) | 0.705 |
Severity based on DDS (
P
< 0.001):
I1: 0.6 ± 0.7 I2: 1.8 ± 0.8 | N/A |
Subcategory | Study | Definition delirium | Evaluation timing (d) | Surgery type | Intervention (I1 vs. I2) | Gender (F/M) | Age (y) | Score | Incidence (n/total) (%) | P value | Delirium duration or severity | Hospital stay (d) |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Liptzin, 2005 [30] | DSM-IV, CAM, DSI | POD 7, POD 14 | Orthopedic | Donepezil (5 mg, po) (pre-1-14+ POD 1-14) vs. placebo | I1: 25/14 I2: 21/20 | I1: 67 ± 9 I2: 68 ± 9 | 6 | I1: 8/39 (20.5%) I2: 7/41 (17.1%) | 0.694 |
Duration (
P
= 0.12):
I1: 1 ± 0 days I2: 1.3 ± 1.2 days | I1: 4.4 ± 0.8 I2: 4.2 ± 0.5 | |
Sampson, 2007 [37] | DSI | POD 1-4 | Orthopedic | Donepezil (5 mg, po) (pre- + POD 1-3) vs. placebo | I1: 8/11 I2: 6/8 | I1: 70 ± 8 I2: 65 ± 11 | 10 | I1: 2/19 (10.5%) I2: 5/14 (35.7%) | 0.106 | I1: 9.9 ± 3.2 I2: 12.1 ± 4.1 | ||
Cholinesterase inhibitors
| Marcantonio, 2011 [48] | CAM, DSI, MDAS | POD 1-discharge; 2, 4, and 6 weeks | Orthopedic | Donepezil (5 mg, po) (POD 1-30) vs. placebo | I1: 5/2 I2: 4/5 | I1: 88 ± 5 I2: 87 ± 4 | 9 | I1: 3/7 (42.9%) I2: 4/9 (44.4%) | 1 |
Severity based on MDAS changes (
P
= 0.91):
I1: 1.3 ± 2.5 I2: 1.6 ± 5.2 | N/A |
Gamberini, 2009 [39] | CAM | POD 1-6 | Orthopedic | Rivastigmine (1.5 mg, tid, po) (pre-1 + POD 1-6) vs. placebo | I1: 19/37 I2: 17/40 | I1: 74 ± 5 I2: 74 ± 6 | 10 | I1: 18/56 (32.1%) I2: 17/57 (29.8%) | 0.790 | I1: 13 ± 6.2 I1: 13 ± 6.2 | ||
Kaneko, 1999 [22] | DSM-III-R | POD 5 | Abdominal | Haloperidol (5 mg, iv) (POD 1-5) vs. saline | I1: 14/24 I2: 14/26 | I1: 72 ± 8 I2: 73 ± 9 | 5 | I1: 4/38 (10.5%) I2: 13/40 (32.5%) |
0.027
| N/A | ||
Antipsychotics (typical)
| Kalisvaart, 2005 [29] | DSM-IV, CAM, DRS | POD 1-3 | Orthopedic | Haloperidol (0.5 mg, tid, po) (pre-POD 3) vs. placebo | I1: 172/40 I2: 171/47 | I1: 79 ± 6 I2: 80 ± 6 | 11 | I1: 32/212 (15.1%) I2: 36/218 (13.8%) | 0.687 |
Severity in patients with delirium based on DRS (
P
< 0.001):
I1: 14.40 ± 3.5 I2: 18.41 ± 4.4
Duration in patients with delirium (
P
< 0.001):
I1: 5.41 ± 4.91 days I2: 11.85 ± 7.56 days | Patients with delirium: I1: 17.1 ± 11.1 I2: 22.6 ± 16.7 |
Wang, 2012 [54] | CAM-ICU | POD 1-7 | Non-cardiovascular | Haloperidol (1.7 mg, iv) (POD) vs. saline | I1: 84/145 I2: 85/143 | I1: 74 ± 6 I2: 74 ± 7 | 12 | I1: 35/229 (15.3%) I2: 53/228 (23.2%) | 0.031 | I1: 11.0 ± 0.9 I1: 11.0 ± 0.8 | ||
Larsen, 2010 [45] | DSM-III-R, CAM, DRS | POD 1-8 or discharge | Orthopedic | Olanzapine (5 mg, po) (pre- + POD) vs. placebo | I1: 94/102 I2: 123/81 | I1: 73 ± 6 I2: 74 ± 6 | 9 | I1: 28/196 (14.3%) I2: 82/204 (40.2%) | < 0.001 |
Severity based on DRS (
P =
0.02):
I1: 16.44 ± 3.7 I2: 14.5 ± 2.7
Duration (
P
= 0.02):
I1: 2.2 ± 1.3 days I2: 1.6 ± 0.7 days | N/A | |
Antipsychotics (atypical)
| Prakanrattana, 2007 [36] | CAM-ICU | POD 1-discharge | Cardiovascular | Risperidone (1 mg, sl) (POD) vs. placebo | I1: 27/36 I2: 25/38 | I1: 61 ± 10 I2: 61 ± 10 | 12 | I1: 7/63 (11.1%) I2: 20/63 (31.7%) | 0.009 | I1: 10.5 ± 6.1 I2: 10.3 ± 4.4 | |
Hakim, 2012 [52] | DSM-IV | ICU -discharge | Cardiovascular | Risperidone (0.5 mg, bid, po) (POD until 24 hours after subsidence of subsyndromal delirium or a score of more than 3 on the ICDSC was obtained) vs. placebo | I1: 18/33 I2: 14/36 | > 65 | 12 | I1: 7/51 (13.7%) I2: 17/50 (34%) | 0.031 |
Duration in patients with delirium (
P
= 0.669):
I1: 3 ± 1.5 days I2: 3 ± 0.8 days | I1: 6 ± 1.5 I2: 6 ± 2.3 | |
Leung, 2006 [33] | CAM | POD 1-3 | Orthopedic | Gabapentin (900 mg, po) (pre- + POD 1-3) vs. placebo | I1: 5/4 I2: 5/7 | I1: 57 ± 10 I2: 61 ± 11 | 10 | I1: 0/9 (0) I2: 5/12 (41.7%) | 0.045 | N/A | ||
Anticonvulsants
| Pesonen, 2011 [50] | CAM-ICU | POD 1-5 | Abdominal | Pregabalin (150 mg, po) (pre- + POD 1-5) vs. placebo | I1: 14/21 I2: 19/16 | I1: 80 ± 11 I2: 80 ± 12 | 10 | N/A | N/A |
Severity based on CAM-ICU (
P
= 0.04):
I1: 24 ± 8 I2: 21 ± 19 | N/A |
Sleep restoration (diazepam/flunitrazepam/pethidine)
| Aizawa, 2002 [26] | DSM-IV | POD 1-7 | Abdominal | Diazepam (0.1 mg/kg, im)/flunitrazepam (0.04 mg/kg, iv)/pethidine (1 mg/kg, iv) (POD 1-3) vs. standard | I1: 5/15 I2: 9/11 | I1: 76 ± 5 I2: 76 ± 4 | 8 | I1: 1/20 (5%) I2: 7/20 (35%) | 0.023 | I1: 25.6 ± 9.4 I2: 29.9 ± 6.2 | |
Sleep restoration (Bright light)
| Taguchi, 2007 [38] | NEECHAM | POD 1-5 | Thoracic | Bright light (2 hours per day; morning; 5000 lx) vs. standard | I1: 0/6 I2: 0/5 | I1: 56 ± 14 I2: 59 ± 14 | 7 | I1: 1/6 (16.7%) I2: 2/5 (40%) | 0.545 |
Severity based on NEECHAM (
P
= 0.014):
I1: 6.7 ± 0.7 I2: 21.1 ± 7 | N/A |
Ono, 2011 [49] | NEECHAM, DSM-IV | POD 1-6 | Thoracic | Bright light (POD2-5; 2 hours per day; morning; 2500-5000 lx) vs. standard | I1: 0/6 I2: 0/5 | I1: 63 ± 10 I2: 64 ± 8 | 6 | I1: 1/10 (10%) I2: 5/12 (41.7%) | 0.162 | I1: 24.8 ± 3.9 I2: 24.8 ± 4.0 | ||
Psychological interventions
| Schindler, 1989 [18] | DSM-III | discharge | Cardiovascular | Daily psychiatric intervention vs. standard | I1: 13/3 I2: 13/4 | I1: 58 ± 8 I1: 61 ± 6 | 3 | I1: 0/17 (0) I2: 2/16 (12.5%) | 0.227 | I1: 15.7 ± 5 I2: 18.7 ± 6 | |
Music
| McCaffrey, 2009 [42] | NEECHAM | POD 1-3 | Orthopedic | Music vs. standard | I1: 7/4 I2: 7/4 | I1: 75 ± 5 I1: 76 ± 6 | 6 | N/A | N/A |
Severity based on NEECHAM (
P
= 0.000):
I1: 24 ± 0.97 I2: 22.5 ± 1.22 | N/A |
Multi-component interventions
| Marcantonio, 2001 [25] | CAM | POD 1-discharge | Orthopedic | Geriatrics consultation (a geriatrician made daily visits for the duration of the hospitalization and made targeted recommendations based on a structured protocol including 10 modules) vs. standard | I1: 49/13 I2: 50/14 | I1: 78 ± 8 I2: 80 ± 8 | 9 | I1: 20/62 (32.3%) I2: 32/64 (50%) | 0.043 |
The number of patients with severe delirium (
P
= 0.02):
I1: 7/62 (11.3%) I2: 18/64 (28.1%)
Duration in patients with delirium (
P
= 0.72):
I1: 2.9 ± 2 days I2: 3.1 ± 2.3 days | I1: 5 ± 1.5 I2: 5 ± 1.5 |
Lundstrom, 2007 [35] | DSM-IV, OBS-scale | POD 1-discharge | Orthopedic | Comprehensive intervention (staff education, team work, individual care planning, prevention and treatment delirium and delirium-related complications) vs. standard | I1: 74/28 I2: 74/23 | I1: 82 ± 7 I2: 82 ± 6 | 9 | I1: 56/102 (54.9%) I2: 73/97 (75.3%) | 0.003 |
Duration (
P
= 0.009):
I1: 5.0 ± 7.1 days I2: 10.2 ± 13.3 days | I1: 28 ± 17.9 I2: 38 ± 40.6 | |
H
2
receptor blockers
| Kim, 1996 [21] | DSM-III | POD1, discharge | Cardiovascular | Cimetidine vs. ranitidine | I1: 14/39 I2: 17/41 | I1: 68 ± 10 I2: 64 ± 11 | 4 | I1: 13/53 (24.5%) I2: 15/58 (25.9%) | 0.872 | I1: 8.9 ± 3.9 I2: 8.7 ± 2.9 |
Quality scores of included studies
Study | Randomization | Allocation concealment | Blinding | Withdrawal or dropouts | ITT analysis | Delirium assessor blinding | Baseline similarity | Delirium follow-up | Total |
---|---|---|---|---|---|---|---|---|---|
Williams-Russo, 1999 [23] | 2 | 2 | 0 | 1 | 1 | 1 | 1 | 2 | 10 |
Berggren, 1987 [17] | 1 | 1 | 0 | 1 | 1 | 1 | 0 | 0 | 5 |
Williams-Russo, 1995 [20] | 2 | 1 | 0 | 1 | 1 | 1 | 1 | 2 | 9 |
Kudoh, 2004 [27] | 2 | 1 | 0 | 1 | 1 | 1 | 0 | 2 | 8 |
Papaioannou, 2005 [31] | 2 | 1 | 0 | 1 | 1 | 0 | 1 | 1 | 7 |
Sieber, 2010 [47] | 2 | 1 | 0 | 1 | 1 | 1 | 1 | 2 | 9 |
Nishikawa, 2004 [28] | 1 | 2 | 0 | 1 | 1 | 1 | 0 | 1 | 7 |
Hudetz, 2009 [40] | 1 | 2 | 0 | 1 | 0 | 1 | 1 | 2 | 8 |
Royse, 2011 [51] | 2 | 2 | 1 | 1 | 0 | 1 | 1 | 0 | 8 |
Leung, 2006 [34] | 2 | 2 | 0 | 0 | 0 | 1 | 1 | 0 | 6 |
Williams-Russo, 1992 [19] | 2 | 1 | 0 | 1 | 0 | 1 | 0 | 2 | 7 |
Mann, 2000 [24] | 2 | 1 | 0 | 1 | 0 | 1 | 1 | 2 | 8 |
Beaussier, 2006 [32] | 2 | 1 | 2 | 1 | 0 | 1 | 0 | 2 | 9 |
Mouzopoulos, 2009 [43] | 2 | 1 | 0 | 1 | 0 | 0 | 1 | 2 | 7 |
Musclow, 2012 [53] | 2 | 2 | 2 | 1 | 1 | 1 | 0 | 2 | 11 |
Maldonado, 2009 [41] | 2 | 1 | 0 | 1 | 1 | 1 | 1 | 1 | 8 |
Shehabi, 2009 [44] | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 2 | 11 |
Rubino, 2010 [46] | 1 | 2 | 2 | 1 | 1 | 1 | 0 | 0 | 8 |
Liptzin, 2005 [30] | 1 | 1 | 2 | 1 | 0 | 1 | 0 | 0 | 6 |
Sampson, 2007 [37] | 2 | 2 | 2 | 1 | 0 | 1 | 0 | 2 | 10 |
Marcantonio, 2011 [48] | 2 | 1 | 2 | 1 | 0 | 1 | 0 | 2 | 9 |
Gamberini, 2009 [39] | 2 | 1 | 2 | 1 | 0 | 1 | 1 | 2 | 10 |
Kaneko, 1999 [22] | 1 | 2 | 0 | 1 | 0 | 0 | 1 | 0 | 5 |
Kalisvaart, 2005 [29] | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 1 | 11 |
Wang, 2012 [54] | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 12 |
Larsen, 2010 [45] | 1 | 1 | 2 | 1 | 1 | 1 | 0 | 2 | 9 |
Prakanrattana, 2007 [36] | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 12 |
Hakim, 2012 [52] | 2 | 2 | 2 | 1 | 1 | 1 | 1 | 2 | 12 |
Leung, 2006 [33] | 2 | 1 | 2 | 1 | 1 | 1 | 1 | 1 | 10 |
Pesonen, 2011 [50] | 2 | 1 | 2 | 1 | 0 | 1 | 1 | 2 | 10 |
Aizawa, 2002 [26] | 1 | 1 | 0 | 1 | 1 | 1 | 1 | 2 | 8 |
Taguchi, 2007 [38] | 2 | 1 | 0 | 1 | 1 | 0 | 0 | 2 | 7 |
Ono, 2011 [49] | 2 | 1 | 0 | 1 | 0 | 0 | 0 | 2 | 6 |
Schindler, 1989 [18] | 1 | 1 | 0 | 1 | 0 | 0 | 0 | 0 | 3 |
McCaffrey, 2009 [42] | 2 | 1 | 0 | 1 | 1 | 0 | 0 | 1 | 6 |
Marcantonio, 2001 [25] | 2 | 2 | 0 | 1 | 1 | 1 | 0 | 2 | 9 |
Lundstrom, 2007 [35] | 2 | 2 | 0 | 1 | 1 | 1 | 0 | 2 | 9 |
Kim, 1996 [21] | 1 | 1 | 0 | 1 | 0 | 1 | 0 | 0 | 4 |
Quantitative review and meta-analysis
Category 1. Perioperative procedures and drugs (Table 2)
1.1 Controlled hypotension
1.2 Neuraxial anesthesia versus general anesthesia
1.3 Sedation depth during spinal anesthesia
1.4 General anesthetics
1.5 Epidural analgesia versus intravenous analgesia
1.6 Additional fascia iliaca compartment block
1.7 Long-acting morphine
1.8 Postoperative sedation using alpha-2 adrenoreceptor agonists
Category 2. Pharmacological, psychological or multicomponent interventions (Table 3)
2.1 Acetylcholinesterase inhibitors
2.2 Antipsychotics
2.3 Anticonvulsants
2.4 Sleep restoration using diazepam, flunitrazepam and pethidine
2.5 Sleep restoration using bright light
2.6 Psychological intervention
2.7 Music
2.8 Multicomponent interventions
2.9 Histamine H2 receptor blockers
Interventions effective in preventing postoperative delirium did not shorten the length of hospital stay
Discussion
Summary of evidence
Conclusions based on | Perioperative procedures and drugs (>, superior to; =, equally effective to; UC*, uncertain) | Pharmacological, psychological or multicomponent interventions (>, superior to; =, equally effective to; UC, uncertain) |
---|---|---|
Meta-analysis
| ||
Single study
| Sedation depth: light > deep [47] Additional ketamine > routine general anesthesia induction [40] Additional fascia iliaca compartment block > standard analgesia [43] | Sleep restoration: diazepam/flunitrazepam/pethidine > standard [26] |
Additional N2O during general anesthesia = standard [34] | Histamine H2 blockers: cimetidine UC ranitidine [21] Psychiatric intervention UC standard [18] Music UC standard [42] | |
Controlled hypotension: mild UC marked [23] Anesthetics plus epidural anesthesia: propofol UC sevoflurane [28] Anesthetics during general anesthesia: propofol UC desflurane [51] Analgesics: Long-acting morphine UC placebo [53] Postoperative sedation: clonidine UC other sedatives [46] |
Limitations
Future directions
Conclusions
Key messages
-
Multiple strategies including perioperative management procedures, pharmacological and nonpharmacological interventions have been used in an effort to prevent postoperative delirium.
-
There is a consensus in the data that dexmedetomidine sedation, multicomponent interventions and antipsychotics are useful in preventing postoperative delirium.
-
Anesthesia types and analgesia methods have no bearing on postoperative delirium.
-
Acetylcholinesterase inhibitors are ineffective in preventing postoperative delirium.
-
Reduced postoperative delirium is not related with shortened hospital stay.