J Korean Neurosurg Soc.  2014 Jul;56(1):28-33. 10.3340/jkns.2014.56.1.28.

Risk Factors for Delirium after Spine Surgery in Elderly Patients

• Seo JS
• Park SW
• Lee YS
• Chung C
• Kim YB

• KMID: 2067073
• DOI: http://doi.org/10.3340/jkns.2014.56.1.28

Abstract

OBJECTIVE
Postoperative delirium is a common complication in the elderly after surgery but few papers have reported after spinal surgery. We analyzed various risk factors for postoperative delirium after spine surgery.
METHODS
Between May 2012 and September 2013, 70 patients over 60 years of age were examined. The patients were divided into two groups : Group A with delirium and Group B without delirium. Cognitive function was examined with the Mini-Mental State Examination-Korea (MMSE-K), Clinical Dementia Rating (CDR) and Global Deterioration Scale (GDS). Information was also obtained on the patients' education level, underlying diseases, duration of hospital stay and laboratory findings. Intraoperative assessment included Bispectral index (BIS), type of surgery or anesthesia, blood pressure, fluid balance, estimated blood loss and duration of surgery.
RESULTS
Postoperative delirium developed in 17 patients. The preoperative scores for the MMSE, CDR, and GDS in Group A were 19.1+/-5.4, 0.9+/-0.6, and 3.3+/-1.1. These were significantly lower than those of Group B (25.6+/-3.4, 0.5+/-0.2, and 2.1+/-0.7) (p<0.05). BIS was lower in Group A (30.2+/-6.8 compared to 35.4+/-5.6 in group B) (p<0.05). The number of BIS <40 were 5.1+/-3.1 times in Group A, 2.5+/-2.2 times in Group B (p<0.01). In addition, longer operation time and longer hospital stay were risk factors.
CONCLUSION
Precise analysis of risk factors for postoperative delirium seems to be more important in spinal surgery because the surgery is not usually expected to have an effect on brain function. Although no risk factors specific to spinal surgery were identified, the BIS may represent a valuable new intraoperative predictor of the risk of delirium.

Keyword

Postoperative delirium; Cognitive function test; Bispectral index

MeSH Terms

Aged*
Anesthesia
Blood Pressure
Brain
Delirium*
Dementia
Education
Humans
Length of Stay
Risk Factors*
Spine*
Water-Electrolyte Balance

Reference

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Washington, DC: American Psychiatric Association;2013.

2. Boos GL, Soares LF, Oliveira Filho GR. [Postoperative cognitive dysfunction : prevalence and associated factors]. Rev Bras Anestesiol. 2005; 55:517–524. PMID: 19468642.

3. Cerejeira J, Firmino H, Vaz-Serra A, Mukaetova-Ladinska EB. The neuroinflammatory hypothesis of delirium. Acta Neuropathol. 2010; 119:737–754. PMID: 20309566.

4. Chan MT, Cheng BC, Lee TM, Gin T. CODA Trial Group. BIS-guided anesthesia decreases postoperative delirium and cognitive decline. J Neurosurg Anesthesiol. 2013; 25:33–42. PMID: 23027226.

5. Deiner S, Silverstein JH. Postoperative delirium and cognitive dysfunction. Br J Anaesth. 2009; 103(Suppl 1):i41–i46. PMID: 20007989.

6. Elie M, Cole MG, Primeau FJ, Bellavance F. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med. 1998; 13:204–212. PMID: 9541379.

7. Fayers PM, Hjermstad MJ, Ranhoff AH, Kaasa S, Skogstad L, Klepstad P, et al. Which mini-mental state exam items can be used to screen for delirium and cognitive impairment? J Pain Symptom Manage. 2005; 30:41–50. PMID: 16043006.

8. Folstein MF, Folstein SE, McHugh PR. "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975; 12:189–198. PMID: 1202204.

9. Gaudreau JD, Gagnon P. Psychotogenic drugs and delirium pathogenesis : the central role of the thalamus. Med Hypotheses. 2005; 64:471–475. PMID: 15617851.

10. Inouye SK. Delirium in older persons. N Engl J Med. 2006; 354:1157–1165. PMID: 16540616.

11. Inouye SK, Foreman MD, Mion LC, Katz KH, Cooney LM Jr. Nurses' recognition of delirium and its symptoms : comparison of nurse and researcher ratings. Arch Intern Med. 2001; 161:2467–2473. PMID: 11700159.

12. Jankowski CJ, Trenerry MR, Cook DJ, Buenvenida SL, Stevens SR, Schroeder DR, et al. Cognitive and functional predictors and sequelae of postoperative delirium in elderly patients undergoing elective joint arthroplasty. Anesth Analg. 2011; 112:1186–1193. PMID: 21415433.

13. Johansen JW. Update on bispectral index monitoring. Best Pract Res Clin Anaesthesiol. 2006; 20:81–99. PMID: 16634416.

14. Kang Y, Na DL, Hahn S. A validity study on the Korean Mini-Mental State Examination (K-MMSE) in dementia patients. J Korean Neurol Assoc. 1997; 15:300–308.

15. Kawaguchi Y, Kanamori M, Ishihara H, Abe Y, Nobukiyo M, Sigeta T, et al. Postoperative delirium in spine surgery. Spine J. 2006; 6:164–169. PMID: 16517388.

16. Lee JK, Park YS. Delirium after spinal surgery in Korean population. Spine (Phila Pa 1976). 2010; 35:1729–1732. PMID: 20150830.

17. Leung JM, Sands LP, Paul S, Joseph T, Kinjo S, Tsai T. Does postoperative delirium limit the use of patient-controlled analgesia in older surgical patients? Anesthesiology. 2009; 111:625–631. PMID: 19672166.

18. Litaker D, Locala J, Franco K, Bronson DL, Tannous Z. Preoperative risk factors for postoperative delirium. Gen Hosp Psychiatry. 2001; 23:84–89. PMID: 11313076.

19. Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. 1998; 86:781–785. PMID: 9539601.

20. Marcantonio ER, Goldman L, Orav EJ, Cook EF, Lee TH. The association of intraoperative factors with the development of postoperative delirium. Am J Med. 1998; 105:380–384. PMID: 9831421.

21. Morimoto Y, Yoshimura M, Utada K, Setoyama K, Matsumoto M, Sakabe T. Prediction of postoperative delirium after abdominal surgery in the elderly. J Anesth. 2009; 23:51–56. PMID: 19234823.

22. Morris JC. The Clinical Dementia Rating (CDR) : current version and scoring rules. Neurology. 1993; 43:2412–2414. PMID: 8232972.

23. Oh YS, Kim DW, Chun HJ, Yi HJ. Incidence and risk factors of acute postoperative delirium in geriatric neurosurgical patients. J Korean Neurosurg Soc. 2008; 43:143–148. PMID: 19096622.

24. Parikh SS, Chung F. Postoperative delirium in the elderly. Anesth Analg. 1995; 80:1223–1232. PMID: 7762856.

25. Plaschke K, Fichtenkamm P, Schramm C, Hauth S, Martin E, Verch M, et al. Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6. Intensive Care Med. 2010; 36:2081–2089. PMID: 20689917.

26. Reisberg B, Ferris SH, de Leon MJ, Crook T. The Global Deterioration Scale for assessment of primary degenerative dementia. Am J Psychiatry. 1982; 139:1136–1139. PMID: 7114305.

27. Reisberg B, Jamil IA, Khan S, Monteiro I, Torossian C, Ferris S, et al. Staging dementia. In : Abou-Saleh M, Katona C, Kumar A, editors. Principles and Practice of Geriatric Psychiatry. ed 33. London: John Wiley & Sons, Ltd;p. 162–169.

28. Rundshagen I, Hardt T, Cortina K, Pragst F, Fritzsche T, Spies C. Narcotrend-assisted propofol/remifentanil anaesthesia vs clinical practice : does it make a difference? Br J Anaesth. 2007; 99:686–693. PMID: 17704091.

29. Saczynski JS, Marcantonio ER, Quach L, Fong TG, Gross A, Inouye SK, et al. Cognitive trajectories after postoperative delirium. N Engl J Med. 2012; 367:30–39. PMID: 22762316.

30. Schuurmans MJ, Duursma SA, Shortridge-Baggett LM, Clevers GJ, Pel-Littel R. Elderly patients with a hip fracture : the risk for delirium. Appl Nurs Res. 2003; 16:75–84. PMID: 12764718.

31. Silverstein JH, Timberger M, Reich DL, Uysal S. Central nervous system dysfunction after noncardiac surgery and anesthesia in the elderly. Anesthesiology. 2007; 106:622–628. PMID: 17325520.

32. Smith PJ, Attix DK, Weldon BC, Greene NH, Monk TG. Executive function and depression as independent risk factors for postoperative delirium. Anesthesiology. 2009; 110:781–787. PMID: 19326492.

33. Steiner LA. Postoperative delirium. Part 1 : pathophysiology and risk factors. Eur J Anaesthesiol. 2011; 28:628–636. PMID: 21785356.

34. Tombaugh TN, McIntyre NJ. The mini-mental state examination : a comprehensive review. J Am Geriatr Soc. 1992; 40:922–935. PMID: 1512391.