Postoperative delirium after major orthopedic surgery

doi:10.5312/wjo.v11.i2.90

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World Journal of Orthopedics

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Observational Study

World J Orthop. Feb 18, 2020; 11(2): 90-106
Published online Feb 18, 2020. doi: 10.5312/wjo.v11.i2.90

Table 1 Incidence for postoperative delirium in specific orthopedic procedures from 2009 to 2014

Procedure	Incidence (%)
Primary THA	0.8
Bilateral THA	0.4
Primary TKA	1.2
Bilateral TKA	1.2
Spine fusion	3.3
Other spine procedures	1.9
Femur/pelvic fracture	7.2
Other procedures	1.0

THA: Total hip arthroplasty; TKA: Total knee arthroplasty.

Table 2 Patient demographics and study population

	POD (Mean +/- SD or n, %), n = 959	Non-POD (Mean +/- SD or n, %), n = 77533	P value
Age, yr	72.7+/-12.9	62.3+/-14.1	< 0.001^a
≥ 70	610 (63.6)	24038 (31.0)	< 0.001^a
Male	389 (40.6)	34777 (44.9)	0.008^a
BMI	28.2+/-6.2	28.0+/-6.1	0.003^a
Procedure type			< 0.001^a
THA	161 (16.8)	19753 (25.5)
TKA	249 (26.0)	20106 (25.9)
Bilateral THA	3 (0.3)	853 (1.1)
Bilateral TKA	29 (3.0)	2337 (3.0)
Spine fusions	140 (14.6)	4135 (5.3)
Other spine procedures	126 (13.1)	6587 (8.5)
Other procedures	251 (26.2)	23762 (30.7)
Trauma			< 0.001^a
Fracture of femur/pelvis	57 (5.9)	731 (0.9)
Other trauma	30 (3.1)	2607 (3.4)
No trauma	872 (90.9)	74195 (95.7)
Length of stay	6.0+/-7.5	3.0+/-3.2	< 0.001^a
Latest creatinine before surgery			< 0.001^a
< 1.2 mg/dL	825 (86.0)	71048 (91.6)
1.2-2.0 mg/dL	123 (12.8)	6229 (8.0)
> 2.0 mg/d	11 (1.2)	256 (0.3)
Preoperative hyponatremia			< 0.001^a
Yes	367 (38.3)	21290 (27.5)
No	591 (61.6)	56190 (72.5)
Missing	1 (0.1)	53 (0.07)
Postoperative thiamine order			< 0.001^a
Yes	119 (12.4)	1390 (1.8)
No	839 (87.5)	76122 (98.2)
Missing	1 (0.1)	21 (0.03)
Atrial fibrillation (present on admission)	130 (13.6)	3815 (4.9)	< 0.001^a
Pressure ulcers (present on admission)	23 (2.4)	323 (0.42)	< 0.001^a
Opioid dependence or long-term use	29 (6.2)	1245 (1.6)	< 0.001^a
Psychiatric disease (present on admission)	356 (37.1)	16716 (21.6)	< 0.001^a
Anesthesia type			< 0.001^a
General	344 (35.9)	16356 (21.9)
Other	578 (60.3)	56067 (72.3)
Missing	37 (3.9)	4510 (5.8)
Patient-controlled analgesia			< 0.001^a
Epidural	413 (43.1)	40991 (52.9)
IV	441 (46.0)	22458 (29.0)
Peripheral nerve infusion	11 (1.2)	949 (1.2)
Missing	94 (9.8)	13135 (16.9)
Received diazepam			< 0.001^a
Yes	98 (10.2)	3135 (4.0)
No	860 (89.7)	74377 (95.9)
Missing	1 (0.1)	21 (0.03)
CT, MRI or both performed			< 0.001^a
Yes	872 (90.9)	64838 (83.6)
No	86 (9.0)	12674 (16.4)
Missing	1 (0.1)	21 (0.03)
ASA score			< 0.001^a
1	7 (0.73)	4933 (6.4)
2	477 (49.7)	53801 (69.4)
≥ 3	438 (45.7)	14274 (18.4)
Missing	37 (3.9)	4525 (5.8)

^aP < 0.05. POD: Postoperative delirium; THA: Total hip arthroplasty; TKA: Total knee arthroplasty; ASA: American society of anesthesiologists; BMI: Body mass index; SD: Standard deviation; CT: Computed tomography; MRI: Magnetic resonance imaging.

Table 3 Total hip arthroplasty patient demographics and study population¹

	POD (Mean +/- SD or n, %), n = 140	Non-POD (Mean +/- SD or n, %), n = 18232	P value
Age, yr	77.6+/-10.4	65.5+/-11.4	< 0.001^a
≥ 70	112 (80.0)	6499 (35.65)	< 0.001^a
Male	57 (40.7)	7891 (43.28)	0.54
BMI	26.7+/-5.2	28.4+/-5.8	< 0.001^a
Length of stay	6.1+/-4.0	3.3+/-1.5	< 0.001^a
Latest creatinine before surgery			< 0.001^a
< 1.2 mg/dL	107 (76.4)	16376 (89.8)
1.2-2.0 mg/dL	29 (20.7)	1781 (9.8)
> 2.0 mg/dL	4 (2.9)	75 (0.4)
Preoperative hyponatremia			< 0.001^a
Yes	40 (28.6)	2525 (13.9)
No	100 (71.4)	15700 (86.1)
Missing	0 (0)	7 (0.04)
Postoperative thiamine order			< 0.001^a
Yes	17 (12.1)	387 (2.1)
No	123 (87.9)	17844 (97.9)
Missing	0 (0)	1 (0.01)
Atrial fibrillation (present on admission)	5 (3.6)	119 (0.7)	< 0.001^a
Pressure ulcers (present on admission)	1 (0.7)	47 (0.3)	0.31
Opioid dependence or long-term use	9 (6.4)	199 (1.1)	< 0.001^a
Psychiatric disease (present on admission)	47 (33.6)	3584 (19.7)	< 0.001^a
Anesthesia type			0.55
General	4 (2.7)	384 (2.1)
Other	136 (97.1)	17805 (97.7)
Missing	0 (0)	40 (0.2)
Patient-controlled analgesia			< 0.001^a
Epidural	102 (72.9)	14235 (78.1)
IV	24 (17.1)	1306 (7.2)
Missing	14 (10)	2691 (14.8)
Received diazepam			0.03^a
Yes	8 (5.7)	453 (2.5)
No	132 (94.3)	17778 (97.5)
Missing	0 (0)	1 (0.01)
CT, MRI or both performed			0.009^a
Yes	127 (90.7)	15616 (85.7)
No	13 (9.3)	2615 (14.3)
Missing	0 (0)	1 (0.01)
ASA score			< 0.001^a
2	73 (52.1)	14667 (80.5)
≥ 3	67 (47.9)	3519 (19.3)
Missing	0 (0)	46 (0.25)

¹Only includes total hip arthroplasty patients with American society of anesthesiologists score of 2 or higher.

^aP value < 0.05. POD: Postoperative delirium; ASA: American society of anesthesiologists; CT: Computed tomography; MRI: Magnetic resonance imaging; BMI: Body mass index; SD: Standard deviation.

Table 4 Total knee arthroplasty patient demographics and study population

	POD (Mean +/- SD or n, %), n = 245	non-POD (Mean +/- SD or n, %), n = 19864	P value
Age, yr	75.1+/-9.3	67.6+/-10	< 0.001^a
≥ 70	171 (69.8)	8304 (41.8)	< 0.001^a
Male	89 (36.3)	7364 (37.1)	0.81
BMI	30.0+/-6.1	30.6+/-6.3	0.13
Length of stay	6.0+/-3.2	3.8+/-1.5	< 0.001^a
Latest creatinine before surgery			< 0.001^a
< 1.2 mg/dL	203 (82.9)	17828 (89.8)
1.2-2.0 mg/dL	37 (15.1)	1954 (9.8)
> 2.0 mg/dL	5 (2.0)	82 (0.4)
Preoperative hyponatremia			0.07
Yes	45 (18.4)	2837 (14.3)
No	200 (81.6)	17019 (85.7)
Missing	0 (0)	8 (0.04)
Postoperative thiamine order			< 0.001^a
Yes	28 (11.4)	332 (1.7)
No	217 (88.6)	19530 (98.3)
Missing	0 (0)	2 (0.01)
Atrial fibrillation (present on admission)	46 (18.8)	1190 (6.0)	< 0.001^a
Pressure ulcers (present on admission)	1 (0.4)	29 (0.2)	0.31
Opioid dependence or long-term use	9 (3.7)	198 (1.0)	0.001^a
Psychiatric disease (present on admission)	77 (31.4)	3915 (19.7)	< 0.001^a
Anesthesia type			0.04^a
General	12 (4.9)	545 (2.7)
Other	233 (95.1)	19252 (96.9)
Missing	0 (0)	67 (0.3)
Patient-controlled analgesia			0.005^a
Epidural	179 (73.1)	15151 (76.3)
IV	38 (15.5)	1801 (9.1)
Peripheral nerve infusion	9 (3.7)	711 (3.6)
Missing	19 (7.8)	2201 (11.1)
Received diazepam			0.003^a
Yes	12 (4.9)	381 (1.9)
No	233 (95.1)	19481 (98.1)
Missing	0 (0)	2 (0.01)
CT, MRI or both performed			0.14
Yes	226 (92.2)	17733 (89.3)
No	19 (7.8)	2129 (10.7)
Missing	0 (0)	2 (0.01)
ASA score			< 0.001^a
1	2 (0.8)	489 (2.46)
2	130 (53.1)	14933 (75.2)
≥ 3	113 (46.1)	4327 (22.0)
Missing	0 (0)	70 (0.4)

^aP value < 0.05. POD: Postoperative delirium; ASA: American society of anesthesiologists; CT: Computed tomography; MRI: Magnetic resonance imaging; BMI: Body mass index; SD: Standard deviation.

Table 5 Spine fusion patient demographics and study population

	POD (Mean +/- SD or n, %), n = 137	non-POD (Mean +/- SD or n, %), n = 4107	P value
Age, yr	67.5+/-12.5	60.1+/-15.6	< 0.001^a
≥ 65	91 (66.4)	1765 (43.0)	< 0.001^a
Male	54 (39.4)	1810 (44.1)	0.28
BMI	28.5+/-6.5	28.1+/-5.9	0.40
Length of stay	9.0+/-5.1	5.6+/-3.6	< 0.001^a
Latest creatinine before surgery			0.01^a
< 1.2 mg/dL	116 (84.7)	3754 (91.4)
1.2-2.0 mg/dL	20 (14.6)	346 (8.4)
> 2.0 mg/dL	1 (0.7)	7 (0.2)
Preoperative hyponatremia			0.16
Yes	43 (31.4)	1070 (26.1)
No	94 (68.6)	3033 (73.9)
Missing	0 (0)	4 (0.1)
Postoperative thiamine order			< 0.001^a
Yes	20 (14.6)	93 (2.3)
No	117 (85.4)	4013 (97.7)
Missing	0 (0)	1 (0.02)
Atrial fibrillation (present on admission)	12 (8.8)	135 (3.3)	0.003^a
Pressure ulcers (present on admission)	3 (2.2)	13 (0.32)	< 0.001^a
Opioid dependence or long-term use	11 (8.0)	124 (3.0)	0.004^a
Psychiatric disease (present on admission)	65 (47.5)	1185 (28.9)	< 0.001^a
Anesthesia type			1
General	136 (99.3)	4052 (98.7)
Other	0 (0)	8 (0.2)
Missing	1 (0.7)	47 (1.1)
Patient-controlled analgesia			1
Epidural	0 (0)	18 (0.4)
IV	136 (99.3)	3968 (96.6)
Missing	1 (0.7)	121 (3.0)
Received diazepam			< 0.001^a
Yes	34 (24.8)	476 (11.6)
No	103 (75.2)	3630 (88.4)
Missing	0 (0)	1 (0.02)
CT, MRI or both performed			0.26
Yes	136 (99.3)	3999 (97.4)
No	1 (0.7)	107 (2.6)
Missing	0 (0)	1 (0.02)
ASA score			< 0.001^a
1	1 (0.7)	214 (5.2)
2	78 (56.9)	2974 (72.4)
≥ 3	57 (41.6)	871 (21.2)
Missing	1 (0.7)	48 (1.2)

^aP < 0.05. POD: Postoperative delirium; ASA: American society of anesthesiologists; CT: Computed tomography; MRI: Magnetic resonance imaging; BMI: Body mass index; SD: Standard deviation.

Table 6 Perioperative risk factors and adjusted association with postoperative delirium by procedure

	THAOR (95%CI), n = 18276	THA P value	TKAOR (95%CI), n = 19987	TKA P value	SFOR (95%CI), n = 4183	SF P value
Age, yr
≥ 70 vs < 70	4.9 (3.0, 7.9)	< 0.001^a	2.16 (1.58, 2.94)	< 0.001^a	-	-
≥ 65 vs < 65	-	-	-	-	2.76 (1.79, 4.25)	< 0.001^a
Male	0.90 (0.60, 1.35)	0.62	0.82 (0.60, 1.12)	0.21	0.73 (0.48, 1.10)	0.13
BMI	0.94 (0.90, 0.98)	0.004^a	0.99 (0.96, 1.02)	0.37	0.99 (0.95, 1.02)	0.46
Latest creatinine value before surgery
1.2-2.0 mg/dL vs < 1.2 mg/dL	1.77 (1.05, 3.00)	0.03^a	0.79 (0.49, 1.27)	0.32	1.40 (0.73, 2.68)	0.31
> 2.0 mg/dL vs < 1.2 mg/dL	4.08 (1.06, 15.66)	0.04^a	1.39 (0.46, 4.20)	0.56	2.26 (0.20, 26.24)	0.51
Preoperative hyponatremia	2.36 (1.54, 3.64)	< 0.001^a	1.25 (0.87, 1.79)	0.23	1.24 (0.82, 1.88)	0.31
PCA route
IV vs Epidural	1.98 (1.19, 3.28)	0.008^a	1.26 (0.83, 1.92)	0.27	-	-
Peripheral nerve infusion vs Epidural	-	-	0.93 (0.47, 1.86)	0.85	-	-
Postoperative thiamine order	5.05 (2.72, 9.37)	< 0.001^a	6.40 (4.00, 10.26)	<0.001^a	6.64 (3.72, 11.85)	<0.001^a
ASA Score
2 vs 1	-	-	1.91 (0.26, 13.88)	0.52	1.90 (0.25, 14.19)	0.53
> 3 vs 1	-	-	3.63 (0.49, 26.74)	0.21	2.38 (0.31, 18.46)	0.41
≥ 3 vs 2	2.01 (1.33, 3.05)	< 0.001^a	-	-	-	-
Anesthesia type
Other vs general	2.92 (0.66, 12.85)	0.16	0.89 (0.43, 1.82)	0.74	-	-
Surgery length	1.00 (1.00, 1.01)	0.10	1.00 (0.99, 1.01)	0.55	1.00 (1.00, 1.00)	<0.001^a
Atrial fibrillation, present on admission	0.97 (0.53, 1.77)	0.91	1.93 (1.32, 2.81)	<0.001^a	2.19 (1.09, 4.41)	0.03^a
Pressure ulcers, present on admission	0.65 (0.08, 5.05)	0.68	-	-	7.56 (1.89, 30.24)	0.004^a
Opioid dependence or long-term use	7.11 (3.26, 15.51)	< 0.001^a	2.98 (1.38, 6.41)	0.005^a	1.88 (0.91, 3.90)	0.09
Parenteral diazepam	5.05 (1.5, 16.97)	0.009^a	4.40 (1.52, 12.75)	0.007^a	2.17 (1.19, 3.97)	0.01^a
Elixhauser comorbidity
Deficiency anemias	1.64 (0.74, 3.63)	0.22	1.10 (0.57, 2.11)	0.78	1.11 (0.42, 2.93)	0.83
Congestive heart failure	2.35 (0.93, 5.96)	0.07	1.59 (0.74, 3.38)	0.23	1.54 (0.39, 6.11)	0.54
Rheumatoid arthritis/collagen vascular diseases	1.06 (0.45, 2.51)	0.900	0.35 (0.13, 0.94)	0.04^a	1.02 (0.49, 2.13)	0.95
Chronic pulmonary disease	1.13 (0.67, 1.92)	0.64	0.84 (0.55, 1.28)	0.41	1.06 (0.65, 1.73)	0.82
Coagulopathy	1.32 (0.39, 4.53)	0.66	1.60 (0.70, 3.62)	0.26	2.80 (1.05, 7.50)	0.04^a
Depression	1.70 (1.05, 2.75)	0.03^a	1.47 (1.02, 2.11)	0.04^a	2.61 (1.73, 3.92)	<0.001^a
Diabetes w/o chronic complications	1.54 (0.90, 2.64)	0.12	1.90 (1.36, 2.66)	< 0.001^a	1.54 (0.92, 2.58)	0.10
Diabetes w chronic complications	2.05 (0.45, 9.23)	0.35	1.77 (0.68, 4.58)	0.24	3.34 (1.02, 10.91)	0.046^a
Hypertension	1.62 (1.06, 2.48)	0.03^a	1.21 (0.59, 1.64)	0.23	1.00 (0.66, 1.51)	0.99
Hypothyroidism	1.01 (0.61, 1.66)	0.98	1.46 (1.06, 2.02)	0.02^a	1.07 (0.65, 1.76)	0.80
Liver disease	0.41 (0.05, 3.22)	0.40	0.70 (0.16, 3.07)	0.63	0.71 (0.15, 3.30)	0.66
Lymphoma	1.33 (0.25, 7.20)	0.74	-	-	-	-
Fluid and electrolyte disorders	0.31 (0.04, 2.43)	0.26	1.41 (0.44, 4.56)	0.57	1.14 (0.36, 3.63)	0.82
Other neurological disorders	2.04 (0.98. 4.27)	0.06	2.79 (1.69, 4.60)	< 0.001^a	2.14 (1.10, 4.14)	0.02^a
Obesity	1.06 (0.53, 2.12)	0.88	0.79 (0.53, 1.19)	0.27	1.56 (0.90, 2.69)	0.11
Peripheral vascular disorders	1.20 (0.47, 3.10)	0.70	1.40 (0.62, 3.16)	0.42	1.68 (0.64, 4.42)	0.30
Psychoses	2.52 (0.81, 7.90)	0.11	6.39 (3.51, 11.62)	< 0.001^a	4.95 (2.38, 10.28)	<0.001^a
Pulmonary circulation disorders	1.20 (0.47, 3.10)	0.70	1.69 (0.89, 3.23)	0.11	1.57 (0.51, 4.88)	0.44
Renal failure	0.94 (0.41, 2.15)	0.88	2.32 (1.31, 4.11)	0.004^a	0.97 (0.39, 2.45)	0.95
Solid tumor w/o metastasis	-	-	1.42 (0.31, 6.45)	0.65	-	-
Valvular disease	1.08 (0.59, 1.97)	0.80	1.23 (0.79, 1.92)	0.37	1.17 (0.61, 2.26)	0.63
Weight loss	0.61 (0.05, 7.46)	0.70	7.14 (0.62, 82.11)	0.11	-	-

^aP < 0.05. POD: Postoperative delirium; THA: Total hip arthroplasty; TKA: Total knee arthroplasty; ASA: American society of anesthesiologists; PCA: Patient-controlled analgesia; SF: Spine fusion surgery; CI: Confidence interval; BMI: Body mass index; OR: Odds ratio.

Citation: Urban MK, Sasaki M, Schmucker AM, Magid SK. Postoperative delirium after major orthopedic surgery. World J Orthop 2020; 11(2): 90-106
URL: https://www.wjgnet.com/2218-5836/full/v11/i2/90.htm
DOI: https://dx.doi.org/10.5312/wjo.v11.i2.90