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  • Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty: a retrospective population-based cohort study

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Original article
Risk factors for postoperative delirium in patients undergoing lower extremity joint arthroplasty: a retrospective population-based cohort study
  1. Stavros Memtsoudis1,2,3,
  2. Crispiana Cozowicz1,2,
  3. Nicole Zubizarreta4,5,
  4. Sarah M Weinstein1,
  5. Jiabin Liu1,
  6. David H Kim1,
  7. Lazaros Poultsides6,
  8. Marc Moritz Berger2,
  9. Madhu Mazumdar4 and
  10. Jashvant Poeran4,5
  1. 1 Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery - Weill Cornell Medical College, New York, New York, USA
  2. 2 Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria
  3. 3 Department for Health Care Policy and Research, Weill Cornell Medical College, New York, NY, USA
  4. 4 Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  5. 5 Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  6. 6 Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA
  1. Correspondence to Dr Stavros Memtsoudis, Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery - Weill Cornell Medical College, New York, NY 10021, USA; memtsoudiss{at}hss.edu

Abstract

Background With an ageing population, the demand for joint arthroplasties and the burden of postoperative delirium is likely to increase. Given the lack of large-scale data, we investigated associations between perioperative risk factors and postoperative delirium in arthroplasty surgery.

Methods This retrospective population-based cohort study, utilized national claims data from the all-payer Premier Healthcare database containing detailed billing information from >25% nationwide hospitalizations. Patients undergoing elective total hip/knee arthroplasty surgery (2006–2016) were included.

The primary outcome was postoperative delirium, while potential risk factors included age, gender, race, insurance type, and modifiable exposures including anesthesia type, opioid prescription dose (low/medium/high), benzodiazepines, meperidine, non-benzodiazepine hypnotics, ketamine, corticosteroids, and gabapentinoids.

Results Among 1 694 795 patients’ postoperative delirium was seen in 2.6% (14 785/564 226) of hip and 2.9% (32 384/1 130 569) of knee arthroplasties. Multivariable models revealed that the utilization of long acting (OR 2.10 CI 1.82 to 2.42), combined long/short acting benzodiazepines (OR 1.74 CI 1.56 to 1.94), and gabapentinoids (OR 1.26 CI 1.16 to 1.36) was associated with increased odds of postoperative delirium. Lower odds of postoperative delirium were seen for neuraxial versus general anesthesia (OR 0.81 CI 0.70 to 0.93) and with the utilization of non-steroidal anti-inflammatory drugs (OR 0.85 CI 0.79 to 0.91) as well as cyclooxygenase-2 inhibitors (OR 0.82 CI 0.77 to 0.89). Age-stratified analysis revealed lower odds with high versus low opioid dose (OR 0.86 CI 0.76 to 0.98) in patients >65 years. Findings were consistent between hip and knee arthroplasties.

Conclusions In this large national cohort, we identified various modifiable risk factors (including anesthesia type and pharmaceutical agents) for postoperative delirium, demonstrating possible prevention pathways.

  • complications
  • regional anesthesia
  • opioids
  • adverse effects

https://doi.org/10.1136/rapm-2019-100700

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    Footnotes

    • Contributors SM helped design the study, conduct the study, analyze the data, write the manuscript and has approved the final manuscript. CC helped design the study, conduct the study, analyze the data, and write the manuscript and has approved the final manuscript. NZ helped conduct the study, analyze the data, and write the manuscript and has approved the final manuscript. SMW helped conduct the study, analyze the data and write the manuscript and has approved the final manuscript. JL helped conduct the study, analyze the data and write the manuscript and has approved the final manuscript. DHK helped conduct the study, analyze the data and write the manuscript and has approved the final manuscript. LP helped conduct the study, analyze the data, and write the manuscript and has approved the final manuscript. MMB helped, conduct the study, analyze the data, and write the manuscript and has approved the final manuscript. MM helped conduct the study, analyze the data, and write the manuscript and has approved the final manuscript. JP helped design the study, conduct the study, analyze the data, and write the manuscript and has approved the final manuscript.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement Data may be obtained from a third party and are not publicly available.