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Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104-4283
(Email: cheunga{at}uphs.upenn.edu).
Delirium is a common adverse event among older persons during hospitalizations. Because of the potential economic and social cost associated with delirium, it has been recognized by the National Quality Measures Clearinghouse of the Agency of Healthcare Research & Quality (AHRQ) as a marker of quality of care and patient safety. This study by Koster and colleagues [1] suggests that postoperative delirium among cardiac surgical patients also has long-term health consequences. Cardiac surgical patients with postoperative delirium had increased mortality rates and increased hospitalizations in addition to neurocognitive and sleep disorders for up to 1.5 years after operation.
Existing studies suggest that postoperative delirium occurs in 15% to 53% of all surgical patients and in 70% to 87% of those who require admission to the intensive care unit, and that elderly patients with diminished mental reserve may be most susceptible [2]. Given these risk factors, it was not surprising that cardiac surgical patients represent a population at risk. When the cognitive deficit becomes permanent, it is referred to as postoperative cognitive dysfunction (POCD), a condition shown to predict hospital length of stay, death, and decline in functional performance [3, 4].
The outcomes associated with delirium in the study by Koster and colleagues were based on the results of a mailed questionnaire with a 100% response rate. The questionnaire was also designed to uncover the problems that they hypothesized, thereby increasing the probability of finding a positive result. Additional studies in larger populations using a validated questionnaire such as the Cognitive Failures Questionnaire (CFQ), the Illness Perception Questionnaire (IPQ), or the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) will be necessary to confirm their findings.
The natural implication of the Koster study, which they suggested, was that preventive measures, early detection, and intervention for delirium may improve outcomes [1]. One large study among hospitalized patients has suggested that early intervention using patient reorientation, environmental modification, and scheduled patient mobility efforts was effective, but other smaller studies failed to demonstrate the effectiveness of these interventions [2]. The problem is particularly challenging for cardiac surgical patients in whom the primary focus during hospitalization is prioritized toward immediate and potentially life-threatening medical problems. Furthermore, if delirium or POCD is a consequence of underlying medical conditions, it may be very difficult if not impossible to treat with measures directed toward the prevention of delirium as an independent condition. Nevertheless, Koster and colleagues have drawn attention to postoperative delirium, demonstrating that it is more than an inconvenient complication of cardiac procedures and carries the very real risk of increased 1- to 2-year mortality after operation.
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