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

Stavros Memtsoudis; Crispiana Cozowicz; Nicole Zubizarreta; Sarah M Weinstein; Jiabin Liu; David H Kim; Lazaros Poultsides; Marc Moritz Berger; Madhu Mazumdar; Jashvant Poeran

doi:10.1136/rapm-2019-100700

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

Reg Anesth Pain Med. 2019 Jul 12:rapm-2019-100700. doi: 10.1136/rapm-2019-100700. Online ahead of print.

Authors

Stavros Memtsoudis^{1

2

3}, Crispiana Cozowicz^{4

2}, Nicole Zubizarreta^{5

6}, Sarah M Weinstein⁴, Jiabin Liu⁴, David H Kim⁴, Lazaros Poultsides⁷, Marc Moritz Berger², Madhu Mazumdar⁵, Jashvant Poeran^{5

6}

Affiliations

¹ Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery - Weill Cornell Medical College, New York, New York, USA memtsoudiss@hss.edu.
² Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medizinische Privatuniversitat, Salzburg, Austria.
³ Department for Health Care Policy and Research, Weill Cornell Medical College, New York, NY, USA.
⁴ Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery - Weill Cornell Medical College, New York, New York, USA.
⁵ Department of Population Health Science and Policy, Institute for Healthcare Delivery Science, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁶ Department of Orthopedic Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
⁷ Department of Orthopedic Surgery, NYU Langone Health, New York, New York, USA.

PMID: 31302641
DOI: 10.1136/rapm-2019-100700

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.

Keywords: adverse effects; complications; opioids; regional anesthesia.