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Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults.
JAMA Surg 2015; 150(12):1134-40JS

Abstract

IMPORTANCE

Major postoperative complications and delirium contribute independently to adverse outcomes and high resource use in patients who undergo major surgery; however, their interrelationship is not well examined.

OBJECTIVE

To evaluate the association of major postoperative complications and delirium, alone and combined, with adverse outcomes after surgery.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization between June 18, 2010, and August 8, 2013. Data analysis took place from December 13, 2013, through May 1, 2015.

MAIN OUTCOMES AND MEASURES

Major postoperative complications, defined as life-altering or life-threatening events (Accordion Severity grade 2 or higher), were identified by expert-panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated medical record review method. The following 4 subgroups were analyzed: (1) no complications or delirium; (2) complications only; (3) delirium only; and (4) complications and delirium. Adverse outcomes included a length of stay (LOS) of more than 5 days, institutional discharge, and rehospitalization within 30 days of discharge.

RESULTS

In the 566 participants, the mean (SD) age was 76.7 (5.2) years, 236 (41.7%) were male, and 523 (92.4%) were white. Forty-seven patients (8.3%) developed major complications and 135 (23.9%) developed delirium. Compared with no complications or delirium as the reference group, major complications only contributed to prolonged LOS only (relative risk [RR], 2.8; 95% CI, 1.9-4.0); by contrast, delirium only significantly increased all adverse outcomes, including prolonged LOS (RR, 1.9; 95% CI, 1.4-2.7), institutional discharge (RR, 1.5; 95% CI, 1.3-1.7), and 30-day readmission (RR, 2.3; 95% CI, 1.4-3.7). The subgroup with complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR, 3.4; 95% CI, 2.3-4.8), institutional discharge (RR, 1.8; 95% CI, 1.4-2.5), and 30-day readmission (RR, 3.0; 95% CI, 1.3-6.8). Delirium exerted the highest attributable risk at the population level (5.8%; 95% CI, 4.7-6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission).

CONCLUSIONS AND RELEVANCE

Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect. Delirium occurs more frequently and has a greater effect at the population level than other major complications.

Authors+Show Affiliations

Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts2Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.William F. Connell School of Nursing, Boston College, Boston, Massachusetts.Division of Geriatric Medicine and Meyers Primary Care Institute, University of Massachusetts Medical School, Worcester.Department of Surgery, University of Colorado, Boulder.Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.Department of Surgery, University of Texas Medical Branch at Galveston, Galveston.Department of Psychiatry and Human Behavior, Warren Alpert Medical School, Brown University, Providence, Rhode Island.Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts2Aging Brain Center, Institute for Aging Research, Hebrew SeniorLife, Boston, Massachusetts.

Pub Type(s)

Journal Article
Multicenter Study
Research Support, N.I.H., Extramural
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, P.H.S.

Language

eng

PubMed ID

26352694

Citation

Gleason, Lauren J., et al. "Effect of Delirium and Other Major Complications On Outcomes After Elective Surgery in Older Adults." JAMA Surgery, vol. 150, no. 12, 2015, pp. 1134-40.
Gleason LJ, Schmitt EM, Kosar CM, et al. Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. JAMA Surg. 2015;150(12):1134-40.
Gleason, L. J., Schmitt, E. M., Kosar, C. M., Tabloski, P., Saczynski, J. S., Robinson, T., ... Inouye, S. K. (2015). Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. JAMA Surgery, 150(12), pp. 1134-40. doi:10.1001/jamasurg.2015.2606.
Gleason LJ, et al. Effect of Delirium and Other Major Complications On Outcomes After Elective Surgery in Older Adults. JAMA Surg. 2015;150(12):1134-40. PubMed PMID: 26352694.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Effect of Delirium and Other Major Complications on Outcomes After Elective Surgery in Older Adults. AU - Gleason,Lauren J, AU - Schmitt,Eva M, AU - Kosar,Cyrus M, AU - Tabloski,Patricia, AU - Saczynski,Jane S, AU - Robinson,Thomas, AU - Cooper,Zara, AU - Rogers,Selwyn O,Jr AU - Jones,Richard N, AU - Marcantonio,Edward R, AU - Inouye,Sharon K, PY - 2015/9/10/entrez PY - 2015/9/10/pubmed PY - 2016/4/20/medline SP - 1134 EP - 40 JF - JAMA surgery JO - JAMA Surg VL - 150 IS - 12 N2 - IMPORTANCE: Major postoperative complications and delirium contribute independently to adverse outcomes and high resource use in patients who undergo major surgery; however, their interrelationship is not well examined. OBJECTIVE: To evaluate the association of major postoperative complications and delirium, alone and combined, with adverse outcomes after surgery. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study in 2 large academic medical centers of 566 patients who were 70 years or older without recognized dementia or a history of delirium and underwent elective major orthopedic, vascular, or abdominal surgical procedures with a minimum 3-day hospitalization between June 18, 2010, and August 8, 2013. Data analysis took place from December 13, 2013, through May 1, 2015. MAIN OUTCOMES AND MEASURES: Major postoperative complications, defined as life-altering or life-threatening events (Accordion Severity grade 2 or higher), were identified by expert-panel adjudication. Delirium was measured daily with the Confusion Assessment Method and a validated medical record review method. The following 4 subgroups were analyzed: (1) no complications or delirium; (2) complications only; (3) delirium only; and (4) complications and delirium. Adverse outcomes included a length of stay (LOS) of more than 5 days, institutional discharge, and rehospitalization within 30 days of discharge. RESULTS: In the 566 participants, the mean (SD) age was 76.7 (5.2) years, 236 (41.7%) were male, and 523 (92.4%) were white. Forty-seven patients (8.3%) developed major complications and 135 (23.9%) developed delirium. Compared with no complications or delirium as the reference group, major complications only contributed to prolonged LOS only (relative risk [RR], 2.8; 95% CI, 1.9-4.0); by contrast, delirium only significantly increased all adverse outcomes, including prolonged LOS (RR, 1.9; 95% CI, 1.4-2.7), institutional discharge (RR, 1.5; 95% CI, 1.3-1.7), and 30-day readmission (RR, 2.3; 95% CI, 1.4-3.7). The subgroup with complications and delirium had the highest rates of all adverse outcomes, including prolonged LOS (RR, 3.4; 95% CI, 2.3-4.8), institutional discharge (RR, 1.8; 95% CI, 1.4-2.5), and 30-day readmission (RR, 3.0; 95% CI, 1.3-6.8). Delirium exerted the highest attributable risk at the population level (5.8%; 95% CI, 4.7-6.8) compared with all other adverse events (prolonged LOS, institutional discharge, or readmission). CONCLUSIONS AND RELEVANCE: Major postoperative complications and delirium are separately associated with adverse events and demonstrate a combined effect. Delirium occurs more frequently and has a greater effect at the population level than other major complications. SN - 2168-6262 UR - https://www.unboundmedicine.com/medline/citation/26352694/Effect_of_Delirium_and_Other_Major_Complications_on_Outcomes_After_Elective_Surgery_in_Older_Adults_ L2 - https://jamanetwork.com/journals/jamasurgery/fullarticle/10.1001/jamasurg.2015.2606 DB - PRIME DP - Unbound Medicine ER -